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NOT  TO  CIRCULATES 


not  to  CIRCULATE 


DANDY-WALKER  SYNDROME: 

PRESENTATION  OF  CONGENITAL  FORMATION  IN  AN  OLDER  PATIENT 


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lower  extremities  are  greatly  improved  and  can 
serve  as  an  alternative  to  invasive  conventional 
angiography.  Medicare  now  provides 
coverage  and  has  approved  MRA 
as  an  appropriate  test  in  determining 
the  extent  of  peripheral  vascular 
disease  in  the  lower  extremities. 
Additionally,  MRA  has  been  shown  to  find 
occult  flow  in  blood  vessels  where  it  was  not 
apparent  on  conventional  angiography. 

MRA  is  a non-invasive  test  and  requires 
no  iodi noted  contrast,  which  reduces  the  risk 
of  complications  and  allergic  reactions.  So,  if 
you  have  a patient  who  would  benefit  from  an 
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RUNON/RUNOFF 


EDITOR 

CONWAY  S.  MAGEE,  MD 

CHIEF  EXECUTIVE  OFFICER 

DAVE  TARVER 

GENERAL  MANAGER 

CATHY  LEWIS 

MANAGING  EDITOR 

CANDACE  J.  DAVIS 

ADVERTISING  SALES 

ANNE  GOOCH 

ADMINISTRATIVE  ASSISTANT 

MELISSA  CANTRELL 


VOL  152,  NO.  1 


ESTABLISHED  1844 


£/  JANUARY  2000 


JOURNAL 

“ OF  THE  LOUISIANA  STATE  MEDICAL  SOCIETY 


BOARD  OF  TRUSTEES 

Chairman,  CONWAY  S.  MAGEE,  MD 
K.  BARTON  FARRIS,  MD 
W.  CHARLES  MILLER,  MD 
EMILE  K.  VENTRE  JR,  MD 
Ex  officio,  C.  Clinton  Lewis,  MD 

EDITORIAL  BOARD 
A.  JOANNE  GATES,  MD 
RODNEY  C.  JUNG,  MD 
PATRICK  W.  PEAVY,  MD 
TRENTON  L.  JAMES  II,  MD 
JACK  P.  STRONG,  MD 
CLAY  A.  WAGGENSPACK  JR,  MD 
WINSTON  H.  WEESE,  MD 

LSMS  BOARD  OF  GOVERNORS 
C.  CLINTON  LEWIS,  MD 
DUDLEY  M.  STEWART,  MD 
KEITH  DESONIER,  MD 
LEO  L.  LOWENTRITT  JR,  MD 
K.  BARTON  FARRIS,  MD 
RUSSELL  C.  KLEIN,  MD 
WALLACE  H.  DUNLAP,  MD 
VINCENT  A.  CULOTTA  JR,  MD 
RICHARD  J.  PADDOCK,  MD 
BARRY  G.  LANDRY,  MD 
WILLIAM  T.  HALL,  MD 
JOSEPH  BUSBY  JR,  MD 
LYNN  Z.  TUCKER,  MD 
R.  MARK  WILLIAMS,  MD 
MARTIN  B.  TANNER,  MD 
MARTIN  J.  DUCOTE  JR,  MD 
MARCUS  L.  PITTMAN  III,  MD 
CHARLES  D.  BELLEAU,  MD 
JOSHUA  LOWENTRITT,  MD 
LAURA  BRESNAHAN 

ESTABLISHED  1844.  Owned  and  edited  by  The 
Journal  of  the  Louisiana  State  Medical  Society,  Inc., 
6767  Perkins  Road,  Baton  Rouge,  LA  70808; 
phone:  (225)  763-2310;  fax  (225)  763-2332. 

e-mail:  publicaffairs@lsms.org 
Internet:  www.lsms.org 

Copyright  2000  by  The  Journal  of  the 
Louisiana  State  Medical  Society,  Inc. 

Subscription  price  is  $35  per  year  in  advance, 
postage  paid  for  the  United  States;  $50  per  year  for 
all  foreign  countries  belonging  to  the  Postal  Union. 

Advertising:  Contact  Anne  Gooch,  6767  Perkins 
Road,  Baton  Rouge,  LA  70808;  (225)  763-2310  or 
at  (504)  895-5189,  in  New  Orleans. 

Postmaster:  Send  address  changes  to 
6767  Perkins  Road,  Baton  Rouge,  LA  70808. 

The  Journal  of  the  Louisiana  State  Medical  Society 

(ISSN  0024-6921)  is  published  monthly 
at  6767  Perkins  Road,  Louisiana  State  Medical 
Society,  Baton  Rouge,  LA  70808.  Periodical  postage 
paid  at  Baton  Rouge,  LA  and 
additional  mailing  offices. 

Articles  and  Advertisements  published  in  the 
Journal  are  for  the  interests  of  its  readers  and  do 
not  necessarily  represent  the  official  position  or 
endorsement  of  The  Journal  of  the  Louisiana  State 
Medical  Society,  Inc.  or  the  Louisiana  State  Medical 

Society. 

The  Journal  reserves  the  right  to  make  the  final 
decision  on  all  contents  and  advertisements. 


ARTICLES' 


Theodore  F.  Thurmon,  MD  21 


Praveen  Reddy,  MD  31 

Prasad  S.S.V.  Vannemreddy,  MD 
Laurie  Grier,  MD 
Anil  Nanda,  MD 

Kim  Edward  LeBlanc,  MD,  PhD  35 

Glenn  N.  Jones,  PhD 

Timothy  J.  Dozier,  MD  41 

John  Kalmar,  MD 


DEPARTMENTS 


2 

INFORMATION  FOR  AUTHORS 

C.  Clinton  Lewis,  MD 

5 

PRESIDENT'S  MESSAGE 
Our  Access  to  Better  Care  Plan 

Mrs.  Karen  Depp 

7 

LSMS  ALLIANCE 

The  Value  of  Membership 

Jorse  1.  Martinez-Lopez,  MD 

8 

ECG  OF  THE  MONTH 
Readins  T Leaves 

L.  Nicole  Murray,  MD 
Ronald  G.  Amedee,  MD 

10 

OTOLARYNGOLOGY/HEAD  & NECK 

SURGERY  REPORT 

Recurrent  Aphthous  Stomatitis 

Maria  Calimano,  MD 
Robert  Perret,  MD 
Harold  Neitzschman,  MD 

16 

RADIOLOGY  CASE  OF  THE  MONTH 

Right  Upper  Quadrant  Pain  and  Palpable  Mass 

Gustavo  A.  Colon,  MD 

18 

THE  JOURNAL  150  & 100  YEARS  AGO 
January  1850  and  1900 

43 

CALENDAR 

45 

CLASSIFIED  ADVERTISING 

HOW  CAN  GENETICS  HELP  IN 
THE  MANAGEMENT  OF  OBESITY 

DANDY-WALKER  SYNDROME: 

PRESENTATION  OF  THE  CONGENITAL  FORMATION 
IN  AN  OLDER  PATIENT 


LAFAYETTE'S  FAMILY  PRACTICE  RESIDENCY  PROGRAM: 
PRACTICE  PATTERNS  OF  GRADUATES 

QUADRICEPS  SPARING  MYOPATHY 


Eusene  New 
New  Orleans 


J La  State  Med  Soc  VOL  1 52  January  2000 


Information  for  Authors  (expanded) 


THE  JOURNAL  IS  PUBLISHED  FOR  THE  BENEFIT  of  the  members  of 
the  Louisiana  State  Medical  Society.  Manuscripts  should  be  of  interest  to  a 
broad  spectrum  of  physicians  and  designed  to  provide  practical  information 
on  the  current  status,  progress,  and  changes  in  the  field  of  clinical  medicine. 
The  articles  published  are  primarily  original  scientific  studies  but  may  in- 
clude societal,  socioeconomic,  or  medicolegal  topics. 

Review  Process 

Each  submission  is  reviewed  by  the  editor  and  is  subject  to  peer  review  by 
one  of  the  editorial  consultants.  Manuscripts  are  also  subject  to  editorial 
revision  and  to  such  modification  as  to  bring  them  into  conformity  with 
journal  style.  The  final  decision  to  accept  or  revise  falls  to  the  editor.  Crite- 
ria for  acceptance  include  perceived  interest  to  The  Journal  readers,  sound- 
ness of  scientific  observations  and  conclusions,  timeliness,  originality,  pres- 
ence of  a substantial  take-home  message,  and  quality'  of  writing. 

Preparation  of  the  Typescript 

Print  in  black  ink  on  heavy,  white,  8V2-  by  1 1-inch  bond  paper,  one  side  only, 
using  a standard  upright  typeface  of  letter  quality  in  10-  to  14-point  size. 

Allow  margins  of  at  least  1 inch  on  all  sides;  preferably  use  left  justifica- 
tion (ragged  right);  avoid  end-of-line  hyphens;  number  all  pages  consecu- 
tively, starting  with  the  title  page;  begin  each  major  section  of  the  manu- 
script on  a new  page;  double-space  all  parts  of  the  manuscript. 

Unless  previous  arrangements  have  been  made  with  the  editors,  limit 
the  length  of  the  paper  to  10  pages  as  printed  in  The  Journal  (20-25  pages 
of  the  usual  typescript). 

Submit  the  manuscript  in  triplicate. 

Computer  Disk 

Do  not  send  a diskette  with  the  inital  submission  of  your  manuscript.  After 
the  manuscript  has  been  finally  revised  and  accepted,  the  author  will  be  asked 
to  submit  a 3.5"  diskette  with  files  exactly  matching  the  language  of  the 
accepted  version.  The  Journal  prefers  files  prepared  in  PC  format  and 
Microsoft  Word. 

Style  Conventions 

Acronyms,  abbreviations,  and  initialisms  should  be  used  sparingly.  If  used, 
the  shortened  form  should  be  added  in  parentheses  immediately  following 
the  first  mention  of  the  expanded  form. 

Units  of  measure  should  be  entered  in  conventional  units.  If  essential, 
Systeme  International  (SI)  units  may  be  added  in  parentheses  immediately 
following  the  conventional  expression. 

38°C  3.3  mg/dL  100  mL/hr 

Drug  names  should  be  entered  in  the  generic  form.  If  the  proprietary  name 
is  especially  relevant  to  the  study,  it  may  be  added  in  parentheses  immedi- 
ately following  the  first  mention  of  the  generic  name.  A generic  name  is 
lowercased;  a proprietary  name  is  capitalized. 

Laboratory  procedures  which  are  unusual  should  show  normal  values  in 
parentheses  immediately  following  the  reported  value. 

Names  of  organisms  should  include  full  genus  and  species  at  first  mention; 
the  genus  name  may  be  abbreviated  at  later  mention  of  the  same  organism; 
capitalize  genus,  lowercase  species;  set  entire  name  italic. 

Statistical  statements  should  have  an  explanation  of  their  meaning  added 
parenthetically. 

Citing  a reference  entry  should  be  by  superscript  arabic  numerals  inserted 
at  a logical  site  in  the  sentence;  place  immediately  after  a word  or  mark  of 
punctuation;  cite  reference  entries  in  the  main  text,  in  tables,  and  in  legends, 
but  not  in  the  abstract. 

Smith1  Brown  et  al2  Several  authors3-4'5 '9 


Parts  of  the  Manuscript 

Title  page.  The  title  page  should  carry  the  following  information:  f 1 1 The 
title  of  the  manuscript,  which  should  be  concise,  clear,  and  informative.  Do 
not  use  acronyms  or  abbreviations  in  the  title;  (2)  The  full  name  of  each 
author  together  with  his  highest  academic  degree  relevant  to  the  subject 
matter  of  the  paper.  List  authors  in  the  order  of  the  magnitude  of  their 
contribution.  List  as  authors  only  those  who  have  contributed  substantially 
to  the  design  or  conduct  of  the  study  or  to  the  preparation  of  the  manu- 
script; (3)  The  department  and  institution  of  each  author  at  the  time  the 
study  was  done;  (4)  The  current  institutional  affiliation  of  each  author  if  it 
has  changed;  (5)  Explanatory  notes  that  give:  (a)  a brief  biographical  note 
for  each  author  indicating  his  academic  appointments,  hospital  affiliations, 
and  practice  location;  and  (b)  the  name  and  address  of  the  author  to  whom 
requests  for  reprints  should  be  addressed,  or  a statement  that  reprints  will 
not  be  available. 

Abstract  and  Keywords.  The  abstract  is  a brief  recapitulation  of  the  pur- 
pose of  the  paper,  the  methods  and  subjects  used,  the  results,  and  the  con- 
clusions. 

Avoid  use  of  acronyms,  abbreviations,  and  initialisms;  do  not  cite  refer- 
ences, tables,  or  figures  (the  abstract  must  stand  alone);  limit  the  abstract  to 
150  words. 

On  the  lower  part  of  the  same  page,  list  three  to  five  key  words  or  short 
phrases  that  will  assist  indexers.  Use  terms  from  Medical  Subject  Headings  as 
used  in  Index  Medicus  when  possible. 

Main  Text.  Avoid  highly  technical  expressions  and  jargon;  the  article  should 
be  easily  understood  by  the  general  readership. 

Use  subheads  freely  to  break  the  typographic  monotony,  make  the  pa- 
per easier  to  read,  and  fortify  the  sequence  of  the  author’s  argument.  Com- 
monly used  subheads  are:  introduction  or  background,  methods  and  sub- 
jects, results,  discussion,  and  conclusions. 

Acknowledgments.  Acknowledgment  must  be  made  for  financial  assistance 
(grants,  equipment,  drugs)  and  for  the  use  of  previously  published  material. 

Acknowledgment  may  be  made  for  technical  assistance  and  intellectual 
participation  in  conducting  the  study  or  preparing  the  manuscript. 

The  recognition  of  assistance  should  be  stated  as  simply  as  possible,  with- 
out effusiveness  or  superlatives. 

References.  Each  source  cited  in  the  main  text,  tables,  or  legends  must  be 
listed  in  the  References  section;  and,  conversely,  all  entries  in  the  References 
section  must  have  been  cited  in  the  main  text,  tables,  or  legends. 

Each  reference  entry  is  composed  of  three  elements. 

A reference  entry  for  an  article  in  a journal  is  composed  of  the  following 
three  elements:  (1)  name  of  author,  (2)  title  of  the  article,  and  (3)  the  loca- 
tion of  the  article. 

The  three  elements  of  a reference  entry  for  a book  or  monograph  are: 
(1)  name  of  author,  (2)  title  of  the  book  or  monograph,  and  (3)  facts  of 
publication. 

Name  of  author  (journal  article  or  book):  Give  last  name,  initials,  senior- 
ity indicator;  list  one,  two,  or  three  authors;  if  more  than  three  authors,  list 
the  first  three  and  follow  with  “et  al”;  separate  the  names  with  commas. 

Title  of  a journal  article:  Capitalize  in  sentence  style. 

Title  of  a book  or  monograph:  Capitalize  in  headline  style;  italicize  or  un- 
derline to  indicate  that  the  title  is  to  be  printed  italic. 

Publication  data  for  a journal  article:  Give  abbreviated  name  of  journal, 
year  of  publication,  volume  number,  first  and  last  page.  Abbreviate  name  of 
journal  in  accordance  with  style  used  in  List  of  Journals  Indexed  in  Index 
Medicus ; italicize  name  of  journal  or  underline  to  indicate  that  the  name  of 
The  Journal  is  to  be  printed  italic;  do  not  omit  digits  from  first  or  last  page 
numbers. 

Publication  data  for  a book  or  monograph:  City  where  published,  name  of 
publisher,  year  of  publication,  first  and  last  pages. 

The  following  six  examples  illustrate  the  reference  style  adopted  by  The 
Journal  for  (1)  a reference  to  an  article  in  a journal,  (2)  a reference  to  a 
book  or  monograph,  (3)  a reference  to  a part  of  a larger  work,  (4)  an  orga- 
nization as  an  author,  (5)  a reference  to  a government  publication,  (6)  a 
reference  to  a presentation  at  a societal  meeting,  (7)  a reference  to  an  article 


2 J La  State  Med  Soc  VOL  1 52  January  2000 


Information  for  Authors  (expanded) 


in  a newspaper,  and  (8)  a reference  to  a book  which  has  been  accepted  for 
publication  but  has  not  yet  been  published. 

1 . Brush  JE  Jr,  Cannon  RO  III,  Schenke  WH,  et  al.  Angina  due  to 
coronary  microvascular  disease  in  hypertensive  patients  without 
left  ventricular  hypertrophy.  N Engl  J Med  1988;319:1302-1307. 

2.  Hajdu  SI.  Pathology  of  Soft  Tissue  Tumors.  Philadelphia,  Pa:  Lea  & 
Febiger;  1979:60-83. 

3.  Robinson  BH.  Lactic  acidemia.  In:  Scriver  CR,  Beaudet  AL,  Sly 
WS,  et  al  (editors).  The  Metabolic  Basis  of  Inherited  Disease,  6th 
edition.  New  York:  McGraw-Hill;  1989:869-888. 

4.  American  College  of  Physicians.  Comprehensive  functional 
assesment  of  elderly  patients.  Ann  Intern  Med  1988;109:70-72. 

5.  Office  of  Smoking  and  Health.  The  Health  Consequences  of 
Involuntary  Smoking:  A Report  of  the  Surgeon  General,  1986. 
Rockville,  Md:  US  Department  of  Health  and  Human  Resources; 
1987:97-106  [CDC  publication  87-8398], 

6.  Schacter  RK,  Arluk  J.  Flexural  microflora  in  patients  with  psoriasis. 
Presented  at  the  Annual  Meeting  of  the  American  Academy  of 
Dermatology,  New  Orleans,  La,  December  4-6,  1982. 

7.  Altman  LK.  Experts  change  guides  for  using  drugs  for  HIV.  New 
York  Times  June  27,  1993:1,23. 

8.  Levine  S,  Walsh  D,  Amic  B,  et  al  (editors).  Society  and  Health 
Foundations  for  a Nation.  London:  Oxford  University  Press  [in 
press]. 

Type  each  reference  entry  as  a separate  hanging  paragraph;  number  the  en- 
tries consecutively  in  the  order  cited;  do  not  list  alphabetically;  double-space 
reference  entries;  and  punctuate  as  shown  in  the  examples  above. 

Limit  references  to  15  unless  special  arrangements  have  been  made  with 
the  editors. 

Personal  communications  and  unpublished  data  should  not  be  cited  or 
entered  in  the  list  of  references,  but,  if  essential,  may  be  integrated  paren- 
thetically with  the  text. 

The  authors  are  responsible  for  the  accuracy  of  the  citations  and  the 
reference  entries.  The  authors  are  expected  to  have  read  and  verified  all  of 
the  listed  references. 

Tables.  A table  consists  of  a caption  (table  number  and  title),  the  body  of 
the  table,  and  footnotes.  Tables  should  be  self-explanatory  and  should  supple- 
ment, not  duplicate,  the  main  text.  All  tables  should  have  been  referred  to  in 
the  main  text. 

Type  each  table  on  a separate  page;  number  tables  in  the  order  first 
cited;  provide  a title;  avoid  vertical  rules;  consult  recent  issues  of  The  Jour- 
nal for  examples. 

Limit  tables  to  one  table  (or  one  figure)  per  1000  words  of  text. 

Illustrations 

Illustrations  include  graphs,  charts,  maps,  line  drawings,  photographs,  and 
other  art  work. 

All  illustrations  should  have  been  referred  to  in  the  text.  An  illustration 
and  its  legend  must  stand  alone.  Illustrations  should  be  professionally  pre- 
pared (photocopied  or  computer-generated  figures,  if  of  professional  qual- 
ity, may  be  acceptable  at  the  option  of  the  editors).  Four-color  illustrations 
are  acceptable  at  the  author’s  expense. 

Affix  a label  to  the  back  of  each  illustration  listing  the  figure  number,  the 
name  of  the  first  author,  the  title  of  the  manuscript,  and  an  arrow  indicating 
the  top  of  the  figure.  Do  not  mark  directly  on  the  face  of  the  figure;  do  not 
write  on  the  back  of  the  figure;  do  not  use  paper  clips  or  staples. 

Limit  illustrations  to  one  figure  (or  one  table)  per  1000  words  of  text; 
consult  recent  issues  of  The  Journal  for  examples  of  figures.  Number  the 
figures  in  the  order  first  cited  in  the  text. 

Legends.  A legend  consists  of  a figure  number,  a description  of  the  figure. 


an  explanation  of  any  notations  on  the  figure,  the  techniques  used,  and  an 
acknowledgment  of  the  source  if  the  figure  has  been  previously  published. 
Type  all  legends  on  a separate  sheet;  use  block  paragraphs. 

Cover  Letter 

The  manuscript  must  be  accompanied  by  a cover  letter  which:  (1)  requests 
consideration  of  the  paper  for  publication  in  The  Journal;  (2)  states  that  the 
paper  has  not  been  published  previously  and  is  not  currently  being  consid- 
ered by  another  journal;  (3)  acknowledges  any  potential  conflict  of  interest; 
(4)  states  that  the  final  version  of  the  manuscript  has  been  read  and  approved 
by  all  of  the  authors;  (5)  designates  one  of  the  authors  as  corresponding 
author  and  lists  his  full  mailing  address,  phone  number,  fax  number,  and  e- 
mail  address;  and  (6)  has  been  signed  by  all  of  the  authors. 

Permissions 

Written  permission  must  be  obtained  from:  (1)  any  individual  who  is  recog- 
nizable in  text  or  illustration,  (2)  the  copyright  owner  of  any  previously  pub- 
lished matter  (text,  table,  or  figure)  which  is  to  be  incorporated  in  the  manu- 
script, (3)  any  individual  mentioned  in  the  acknowledgments,  and  (4)  any 
individual  quoted  from  personal  contact. 

If  human  research  was  involved,  a report  from  the  Institutional  Review 
Board  should  be  attached. 

Copyright  Transfer 

Authors  will  be  asked  to  sign  a form  transferring  to  The  Journal  copyright 
ownership  of  any  article  accepted  for  publication.  Such  articles  may  not  be 
republished,  in  whole  or  in  part,  without  written  permission  from  the  edi- 
tors. 

Galley  Proofs 

Galley  proofs  will  be  mailed  to  the  corresponding  author  for  review,  correc- 
tion, and  approval. 

Reprints 

Order  forms  and  pricing  information  for  reprints  will  be  included  with  the 
galley  proofs. 

Editorial  Assistance 

An  expanded  version  of  Information  for  Authors  is  published  in  the  January 
and  July  issues  of  The  Journal.  For  further  help  in  preparing  your  manu- 
script or  for  questions  about  the  editorial  process,  you  may  write  the  Editor 
or  the  Managing  Editor  at  the  address  below.  Or,  if  you  perfer,  contact  either 
the  Editor  (Dr  Magee)  at  (337)  439-8450,  Fax  (337)  439-7576;  E-mail: 
conwaystonemagee@compuserve.com;  or  the  Managing  Editor  at  (225)  763- 
8500,  Fax  (225)  763-2332,  E-mail:  publicaffairs@lsms.org. 

Final  Check 

All  authors  are  expected  to  have  read  the  final  draft  of  the  manuscript  before 
it  is  submitted.  The  corresponding  author  will  be  responsible  for  the  validity 
of  the  content  and  the  accuracy  of  the  typescript  and  for  compliance  with 
published  style  conventions  of  The  Journal.  A guide  sheet  titled  Check  List 
for  Authors  is  available  from  the  editors. 

Submission  of  the  Manuscript 

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J La  State  Med  Soc  VOL  1 52  January  2000  3 


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PRESIDENT’S  MESSAGE 


Our  Access  to  Better  Care  Plan 

C.  Clinton  Lewis,  MD 


The  LSMS  proposes  a voucher  approach  for 
the  Medicaid  Program.  In  1995,  the  legisla- 
ture passed  Act  1242  (R.S.  46:160  et  seq),  the 
Access  to  Better  Care  Medical  Insurance  Demonstra- 
tion Project , an  LSMS  introduction,  which  estab- 
lished as  a pilot  project  a voucher  system  for  Med- 
icaid recipients,  incorporating  high  deductible 
catastrophic  health  insurance  and  medical  savings 
accounts  for  the  medically  indigent.  However,  to 
date,  the  Department  of  Health  and  Hospitals  has 
not  been  able  to  implement  the  voucher  pilot 
project. 

In  the  1999  Regular  Session,  SCR  22  passed, 
which  authorized  DHH  to  implement  a Medicaid 
Region  III  modified  CommunityCARE  program, 
a Medicaid  voucher  program,  a Medicaid  center 
of  excellence  program,  and  a Medicaid  regional 
managed  care  pilot  program.  Implementation  of 
these  programs  would  require  DHH  to  secure  the 
necessary  waivers  from  Health  Care  Financing 
Administration  (HCFA).  SB  221  also  passed  in  the 
1999  Regular  Session  and  became  Act  642.  Act  642 
requires  that  any  modification  to  the  Medical  As- 
sistance Program  approved  by  a HCFA  waiver, 
which  includes  a managed  care  or  voucher  sys- 
tem, requires  approval  of  the  House  and  Senate 
Committees  on  Health  and  Welfare  and  the  Joint 
Committee  on  the  Budget.  In  order  to  facilitate 


implementation  of  a managed  care  or  voucher  sys- 
tem, Act  642  repealed  the  requirement  for  approval 
by  both  houses  of  the  legislature  during  a regular 
or  extraordinary  session. 

A voucher  system  would  increase  the  patient's 
freedom  to  choose  his  or  her  physician,  decrease 
public  outlays,  reduce  overall  health  care  costs  by 
eliminating  cost-shifting,  increase  access  to  qual- 
ity care,  and  empower  the  needy  to  make  decisions 
about  their  health  care  needs.  This  is  not  a new 
concept.  Governments  at  all  levels  have  been  do- 
ing this  for  years,  tapping  into  the  efficiencies  and 
expertise  available  in  the  private  sector. 

The  Access  to  Better  Care  plan  would  accom- 
plish these  results  by  providing  a publicly  financed 
voucher  to  eligible  Medicaid  recipients.  The 
voucher,  limited  to  the  categorically  needy  and 
AFDC-eligible  recipients,  would  be  used  to  pur- 
chase a private  health  insurance  plan.  The  array  of 
health  coverage  options  available  to  Medicaid  ben- 
eficiaries could  include  traditional  indemnity- 
based  insurance,  managed  care  plans  such  as 
HMOs  or  PPOs,  or  a benefit-payment  schedule. 
Coupled  with  these  plans  would  be  a medical  sav- 
ings account  (MSA)  designed  to  reward  recipients 
for  prudent  use  of  the  health  delivery  system. 

It  is  widely  agreed  by  those  in  the  private  and 
public  sectors  that  to  ultimately  control  costs  and 


J La  State  Med  Soc  VOL  1 52  January  2000  5 


the  abuses  of  health  care  there  must  be  behavioral 
change.  The  most  lasting  and  rapid  changes  in  be- 
havior come  about  when  there  is  self-motivation 
to  do  so.  The  medical  savings  account  is  a concept 
that  introduces  motivation  or  incentives  into  the 
process  of  wisely  utilizing  health  care  resources. 

Historically,  both  employees  and  employers 
have  saved  money  using  these  types  of  accounts. 
The  Rand  Corporation  found  that  people  spend 
30%  less  with  no  adverse  effects  on  their  health 
when  they  are  spending  their  own  money. 

It  should  be  emphasized  that  Access  to  Better 
Care  breaks  with  recent  tradition  in  regard  to  our 
Medicaid  population.  In  recent  years,  this  popula- 
tion has  had  their  health  care  managed,  directed, 
and  in  many  cases,  provided  by  the  state  of  Loui- 
siana. This  third  party  control  of  the  process  has 
functionally  removed  these  individuals  from  con- 
trolling their  own  "health-care  destiny".  They  be- 
came less  familiar  with  the  overall  system  since 
they  were  effectively  removed  from  the  entire  de- 
cision making  process.  Such  an  approach  fosters 
increasing  dependence  of  these  individuals  on  the 
state  and  does  little  to  increase  feelings  of  self-reli- 
ance and  dignity.  This  third  party  control  over  the 
provision  of  health  care  was  then  "justified"  by 
what  the  LSMS  feels  is  a potentially  detrimental 
assumption:  that  Medicaid  recipients  are  unable 
to  make  the  decisions  necessary  to  secure  their  own 
health  care  services. 

Access  to  Better  Care  achieves  several  impor- 
tant social  functions  in  addition  to  improving  the 
quality  and  affordability  of  health  care.  This  con- 
cept helps  the  Medicaid  recipient  begin  the  pro- 
cess of  more  clearly  understanding  health  care  and 
the  advantages  and  disadvantages  of  different 
health  care  systems.  Equally  important,  this  con- 
cept reorients  the  role  of  government  from  a self- 
perpetuating,  ever  growing,  complex  cradle-to-the- 
grave  provider  of  assistance  to  a government  that 
helps  its  citizens  to  be  more  intelligent  consumers 
with  meaningful  input  into  the  programs  of  which 
they  are  participants. 

Access  to  Better  Care  would  create  savings  by 
the  state  from  the  purchasing  of  private  insurance 
for  less  than  Louisiana  currently  spends  per  Med- 
icaid recipient  and  by  streamlining  the  Medicaid 
bureaucracy.  The  state  of  Louisiana  currently  en- 
gages in  this  practice  to  some  extent  when  it  pur- 


chases Medicare  coverage  for  Medicare-Medicaid 
dually-eligible  beneficiaries.  In  addition,  a fixed 
annual  amount  for  Louisiana  in  the  form  of  a 
voucher  would  make  it  easier  for  Louisiana  to  ac- 
curately budget  for  Medicaid  expenditures,  while 
the  elimination  of  claims  processing,  with  a one- 
time payment,  would  significantly  reduce  the  size 
of  the  state's  Medicaid  bureaucracy.  Privatizing 
Medicaid  would  strengthen  the  private  health  in- 
surance market  and,  thereby,  provide  additional 
tax  revenues. 

In  addition,  providers  are  already  used  to 
dealing  with  private  insurance  entities  and  are  fa- 
miliar with  their  administrative  requirements. 
There  would  then  be  a lesser  need  for  a fiscal  in- 
termediary to  handle  claims  and  payment,  which 
would  reduce  office  administrative  costs  of  pro- 
viders and  increase  the  attractiveness  of  the  Med- 
icaid patient  by  reducing  the  hassle  factor  associ- 
ated with  government  programs. 

Access  to  Better  Care  would  empower  the  needy 
to  make  decisions  and  create  a system  based  on 
choice.  Access  to  Better  Care  would  empower  re- 
cipients to  make  important  decisions  regarding 
their  own  health  care  needs,  moving  them  away 
from  dependency  and  closer  to  self-sufficiency. 
The  voucher  system  would  also  encourage  recipi- 
ents to  make  informed  decisions  regarding  costs. 
The  plan  could  tie  these  decisions  to  incentives, 
such  as  usable  credits  for  unused  benefits,  which 
lead  recipients  to  make  cost-effective  choices.  Fi- 
nally, Access  to  Better  Care  would  allow  individu- 
als to  choose  the  kind  of  health  care  coverage  they 
desire  and  to  choose  their  own  physician. 

The  LSMS  hopes  that  DHH  will  seek  a HCFA 
waiver  to  implement  the  Access  to  Better  Care  plan, 
which  would  provide  an  innovative  solution  to 
controlling  costs  while  improving  the  quality  of 
care. 


6 J La  State  Med  Soc  VOL  1 52  January  2000 


LSMS  ALLIANCE 


THE  VALUE  OF  MEMBERSHIP 

MRS.  KAREN  DEPP 


When  we  speak  of  membership,  we  often 
ask  "what's  in  it  for  me?"  to  determine 
the  value  we  receive.  What  we  most 
need  to  recognize  is  that  the  value  of  membership 
in  any  association  or  group  is  determined  by  the 
individual  members.  The  value  may  well  be  dif- 
ferent for  each  member,  and  it  might  not  be  what 
the  association  perceives  as  the  value  it  delivers. 

The  Louisiana  State  Medical  Society  Alliance 
is  this  year  asking  the  questions  that  will  help  us 
to  determine,  at  the  state  level  as  well  as  the  par- 
ish level,  what  our  value  might  be.  In  the  state  al- 
liance the  value  should  be  different  than  what  it  is 
in  the  local  alliances  and  auxiliaries.  The  purpose 
of  the  state  organization  is  not  what  the  mission 
or  purpose  of  each  individual  component  is.  Try- 
ing to  be  everything  for  everyone  often  results  in 
being  nothing  for  some  and  too  much  for  others. 

Meeting  and  working  with  the  members  of  the 
parish  alliances  has  given  the  Board  of  LSMSA  a 
better  idea  of  what  the  value  of  LSMSA  member- 
ship is  for  individuals  as  well  as  their  component 
alliances.  The  same  holds  true  for  membership  in 
American  Medical  Association  Alliance.  While  we 


might  not  perceive  the  immediate  benefit  of  per- 
sonal membership  in  either  the  LSMSA  or  the 
AMAA,  it  becomes  apparent  through  the  leader- 
ship of  the  parishes  that  value  is  being  delivered. 

While  we  attempt  to  rebuild  our  alliance  for 
the  future,  we  are  recognizing  that  strong  compo- 
nent medical  societies  and  a strong  LSMS  are  criti- 
cal for  our  success.  In  our  efforts  to  strengthen  our 
membership  we  are  including  efforts  to  help  build 
membership  in  our  societies.  The  one  recurring 
message  that  we  are  receiving  is  that  our  alliances 
see  their  role  as  supporting  our  medical  societies 
as  well  as  providing  programs  and  services  to  our 
communities  that  improve  the  health  and  well- 
being of  our  citizens.  There  are  many  organizations 
to  which  we  might  belong,  but  none  have  the  one 
thing  that  our  alliances  and  societies  do — and  that 
is  the  practice  of  medicine  and  the  health  of  our 
communities  is  what  brings  us  to  membership.  To- 
gether the  LSMS  and  the  LSMSA  can  move  into 
the  future  with  a strong  commitment  to  our  pro- 
fession and  our  members.  That  is  both  perceived 
and  delivered  value! 


Mrs  Depp  is  President  of  the  Louisiana  State  Medical  Society  Alliance. 


J La  State  Med  Soc  VOL  152  January  2000  7 


ECG  OF  THE  MONTH 


Reading  T Leaves 


Jorse  I.  Martinez-Lopez,  MD 


A 64-year-old  man  was  admitted  to  the  CCU  complaining  of  sudden  onset  of  chest  tightness  and 
shortness  of  breath  5 hours  earlier.  The  12-lead  ECG  shown  below  was  recorded  on  his  third  hospital  day. 


What  is  your  diagnosis? 
Elucidation  is  on  page  9. 


8 J La  State  Med  Soc  VOL  1 52  January  2000 


ECG  of  the  Month 
Presentation  is  on  page  8. 

DIAGNOSIS — Acute  ischemic  cardiac  syndrome 

The  tracing  shows  sinus  bradycardia,  at  56 
times  a minute.  The  PR  interval  is  normal  and  the 
QRS  complexes  narrow,  findings  which  indicate 
normal  AV  and  intraventricular  conduction. 

Major  abnormalities  in  the  tracing  involve  the 
T waves  and  the  QT  interval.  T waves  are  sharply 
inverted  in  all  leads,  except  in  leads  AVR  and  AVL, 
are  moderately  deep — especially  from  precordial 
leads  V2  through  V6,  and  reach  a maximal  depth 
of  20  mm  from  the  baseline  in  lead  V3 — and  are 
wider  than  normal.  T waves  in  lead  AVR,  which 
normally  are  inverted,  are  distinctly  upright, 
peaked,  and  wide.  In  AVL,  T waves  are  also  up- 
right, even  though  they  are  inverted  in  lead  I.  Last, 
there  is  minimal  downsloping  depression  of  the 
ST  segments  in  association  with  the  inverted  T 
waves. 

Second,  the  QT  interval  is  prolonged,  with  a 
QT  dispersion  that  ranges  from  0.52  sec  to  0.64  sec. 
The  lengthened  repolarization  time  is  caused  solely 
by  prolongation  of  the  duration  of  the  T waves. 

In  the  distant  past,  inverted  T waves  with  the 
characteristic  morphology,  amplitude,  and  width 
found  in  this  tracing  were  referred  to  as  "Pardee- 
type"  of  T waves,  and  their  presence  as  "Pardee 
sign".  In  recent  years,  this  eponymic  designation, 
which  honored  Dr  Pardee,  has  been  replaced  by 
descriptive  terms:  giant  T-wave  inversion,  global 
T-wave  inversion,  and  canyon  T waves. 

At  present,  the  leading  causes  of  giant  T-wave 
inversions  (ie,  > 5 mm)  are  myocardial  ischemia 
and  myocardial  infarction.  Nevertheless,  attempt- 
ing to  arrive  at  a specific  clinical  diagnosis  on  the 
basis  of  the  ECG  abnormalities  alone  is  akin  to 
"reading  T leaves".  These  abnormalities  are  not 
pathognomonic  for  any  single  clinical  disorder. 
Similar  T-wave  changes,  with  or  without  associ- 
ated lengthening  of  the  QT  interval,  can  be  found 
in  a wide  variety  of  cardiac  and  non-cardiac  dis- 
orders. 

In  view  of  the  presenting  symptoms  reported 
by  the  patient  (chest  tightness  and  shortness  of 
breath)  and  the  abnormal  ECG  changes,  primary 
consideration  in  the  differential  diagnosis  should 
be  given  to  ischemic  heart  disease,  in  one  of  its 


acute  forms:  unstable  angina  pectoris  or  myocar- 
dial infarction,  with  or  without  ST-segment  eleva- 
tion. 

Chest  discomfort  and  giant  T-wave  inversions 
may  also  occur  in  non-coronary  cardiac  disorders 
and  may,  in  this  context,  mimic  ischemic  heart  dis- 
ease. Among  these  are  the  following  conditions: 
the  Japanese  form  of  apical  hypertrophy  and  some 
other  types  of  hypertrophic  cardiomyopathy;  stage 
3 pericarditis;  myocarditis;  mitral  valve  prolapse; 
and  cardiac  metastases.  Less  often,  this  abnormal 
T-wave  pattern  is  recorded  in  some  patients  with 
complete  AV  heart  block  and  Stokes-Adams  syn- 
cope, and  in  long-term  ventricular  pacing. 

Whether  giant  T-wave  inversions  are  associ- 
ated with  or  without  prolongation  of  the  QT  inter- 
val, the  pattern  itself  is  not  restricted  to  cardiac 
pathology.  For  this  reason,  the  differential  diag- 
nosis should  include  non-cardiac  causes  of  giant 
T-wave  inversions.  For  example,  the  combination 
of  giant  T-wave  inversions  and  prolonged  QT  in- 
tervals is  a relatively  common  finding  in  some 
patients  with  severe  brain  damage  due  to  intra- 
cerebral hemorrhage,  subarachnoid  hemorrhage 
with  intracerebral  extension,  and  traumatic  brain 
injury.  In  this  setting,  however,  T waves  are  not  as 
sharply  inverted  and  peaked  as  in  acute  ischemic 
heart  disease;  instead,  T waves  are  broad  and  in- 
verted and  have  a rounded  nadir.  Other  non-car- 
diac conditions  in  which  giant  T-wave  inversions 
may  be  found  include  the  following:  pheochro- 
mocytoma;  bilateral  carotid  endarterectomy;  after 
vagotomy;  cocaine  abuse;  flecainide  intoxication; 
and  acute  gastrointestinal  disorders,  such  as  acute 
gall  bladder  disease,  acute  pancreatic  disease,  and 
perforated  duodenal  ulcer. 

A thorough  work-up  of  the  patient  whose  trac- 
ing is  discussed  here  confirmed  a non-Q-wave 
myocardial  infarction  and  combined  aortic  valve 
stenosis  and  regurgitation.  He  underwent 
aortocoronary  bypass  to  the  left  anterior  descend- 
ing coronary  artery  and  aortic  valve  replacement. 


Dr.  Martinez-Lopez  is  a specialist  in  cardiovascular  diseases  affiliated 
with  the  Cardiology  Service,  Department  of  Medicine,  Texas  Tech 
University  Health  Sciences  Center  arid  Thomason  General  Hospital 

in  El  Paso,  Texas. 


J La  State  Med  Soc  VOL  1 52  January  2000  9 


o*  Aim 8 : : : sy / 

head  an ; ; v . : ry 


RECURRENT  APHTHOUS  STOMATITIS 


L.  Nicole  Murray,  MD;  Ronald  G.  Amedee,  MD 


Recurrent  aphthous  stomatitis  is  the  most  common  oral  mucosal  disease  in  North  America  but  it  is  com- 
monly misdiagnosed  and  poorly  understood.  Pediatricians,  internists,  otolaryngologists,  oral  surgeons, 
and  dentists  may  all  be  expected  to  treat  this  illness  but  little  formal  training  in  oral  medicine  may  be 
offered  to  many  of  these  health  care  professionals.  This  article  reviews  current  evidence  regarding  etiol- 
ogy, pathogenesis,  natural  history,  and  treatment  of  this  disorder. 


The  word  aphtha  has  been  translated  as  "to 
inflame",  "thrush",  or  simply  "ulcer".  None 
of  these  translations  helps  to  define  the  clini- 
cal entity  that  has  come  to  be  known  as  recurrent 
aphthous  stomatitis  (RAS).  These  lesions  are  com- 
monly called  mouth  ulcers  or  canker  sores,  and 
they  have  been  reported  to  affect  anywhere  from 
5%  to  66%  of  the  North  American  population.1  In- 
terestingly, 60%  of  those  affected  are  members  of 
the  professional  class.2  It  is  important  for  physi- 
cians to  be  able  to  recognize  RAS  and  to  distin- 
guish it  from  other  ulcerative  lesions  of  the  oral 
cavity,  as  prognosis  and  treatment  of  these  diseases 
may  vary  greatly. 

CLINICAL  FEATURES 

Patients  with  recurrent  aphthous  stomatitis 
will  complain  of  recurrence  of  one  or  more  pain- 


ful oral  ulcers  at  intervals  ranging  from  days  to 
months.  The  disease  usually  begins  in  childhood 
or  adolescence  and  may  diminish  in  frequency  and 
severity  with  age.  Ulcers  due  to  RAS  are  confined 
to  the  "soft  mucosa"  of  the  mouth,  or  areas  of 
nonkeratinized  mucosa  that  are  not  immediately 
adherent  to  bone.3  These  areas  include  the  buccal 
and  labial  mucosa,  lateral  and  ventral  tongue,  floor 
of  mouth,  soft  palate,  and  oropharyngeal  mucosa. 
The  only  areas  in  the  mouth  that  are  not  affected 
by  RAS  ulcers  are  the  hard  palate  and  the  attached 
gingiva. 

RAS  is  subdivided  into  three  categories  based 
on  the  size  of  the  ulcers  and  on  disease  severity. 
Most  patients  have  "minor  aphthae",  which  are 
less  than  1 cm  in  diameter  and  heal  completely  in 
7-10  days.  These  usually  involve  a prodromal  stage 
of  prickling  and  burning  for  1-2  days  and  may  oc- 


1 0 J La  State  Med  Soc  VOL  1 52  January  2000 


cur  in  crops  of  1-5  ulcers.  Ulcers  are  shallow  and 
round  to  oval  in  shape  with  a gray-  to  yellow-col- 
ored membrane.  These  ulcers  are  very  painful  for 
about  4 days,  then,  after  several  more  days,  are 
healed  completely  without  scarring.  "Major  aph- 
thae" are  uncommon  and  involve  irregular  deep 
ulcers  of  1-3  cm  in  size.  They  may  have  a raised 
border  and  will  require  up  to  4 weeks  to  heal.  These 
ulcers  leave  extensive  scarring  and  distortion  upon 
healing,  and  these  patients  are  rarely  lesion  free. 
This  disorder  is  also  known  as  Sutton's  disease  or 
periadenitis  mucosa  necrotica  recurrens.  "Herpe- 
tiform  aphthae"  are  also  uncommon  and  consist 
of  crops  of  up  to  150  very  small  (1-3  mm)  ulcers 
that  heal  completely  in  7-10  days.  This  category  of 
RAS  is  unfortunately  named  because  these  ulcers, 
like  all  RAS  ulcers,  are  completely  unrelated  to  the 
herpes  virus. 

ETIOLOGY 

Although  many  theories  for  the  etiology  of 
RAS  have  been  proposed  and  investigated,  none 
has  been  proven.  A viral  association  has  been  sug- 
gested, but  this  is  not  supported  by  the  majority 
of  the  literature.  Occasionally,  viruses  such  as  her- 
pes, varicella-zoster,  or  adenovirus  have  been  cul- 
tured in  patients  with  RAS.  These  viruses  are  ubiq- 
uitous, however,  and  there  are  no  reports  of  suc- 
cessful treatment  of  RAS  with  antiviral  therapy.4 
A bacterial  association  has  also  been  proposed.  An 
L-form  streptococcus  (probably  S sanguinous  or  S 
mitis)  has  been  isolated  from  RAS  patients,  and 
RAS  outbreaks  have  been  associated  with  in- 
creased antibody  titres,  but  this  has  not  been  well 
corroborated,  and  it  is  clear  that  antibacterial  drugs 
do  not  cure  RAS.4 

A great  deal  of  literature  has  focused  on  a 
possible  association  with  estrogen  and  progester- 
one levels  in  women.  A recent  metanalysis  con- 
cluded, however,  that  no  associations  have  been 
clearly  established  between  RAS  and  the  premen- 
strual period,  pregnancy,  or  menopause.5  Atten- 
tion has  also  been  focused  on  anxiety,  stress,  and 
the  "type  A"  personality.  It  is  clear  that  there  is  a 
higher  incidence  of  RAS  among  college,  medical, 
and  dental  students,  and  there  is  also  a higher  in- 
cidence among  elementary  students  of  higher  so- 
cioeconomic status.2  However,  studies  that  have 
attempted  to  link  periods  of  life  stress  to  the  onset 
of  RAS  outbreaks  have  failed.6  There  may  be  a pre- 


dilection towards  RAS  among  certain  HLA  types, 
and  a positive  family  history  may  increase  one's 
risk  for  developing  RAS  by  20%.  These  data  are 
confounded,  however,  by  the  role  that  environ- 
ment and  psychologic  stress  may  play. 

The  role  of  nutrition  is  somewhat  controver- 
sial. Deficiencies  of  B vitamins,  iron,  and  zinc  have 
all  been  implicated  in  small  studies.7  In  patients 
with  documented  vitamin  deficiencies,  replace- 
ment therapy  may  be  of  benefit.  A small  subset  of 
patients  with  gluten-sensitive  enteropathies  may 
experience  outbreaks  of  RAS  that  resolve  with  a 
gluten-free  diet,  but  ulcers  in  the  majority  of  these 
patients  will  not  respond  to  dietary  measures.8 
Sensitivities  to  foods  such  as  nuts,  chocolate,  cere- 
als, tomatoes,  dairy  products,  and  citrus  fruits  have 
also  been  implicated  in  the  etiology  of  RAS.  Avoid- 
ance in  these  patients  may  decrease  the  frequency 
of  outbreaks.8 

The  role  of  noxious  stimuli  has  also  been  in- 
vestigated. Minor  trauma,  such  as  lip  biting,  oral 
burns,  or  dental  procedures,  may  precipitate  an 
outbreak  in  susceptible  persons.6  Nicotine,  inter- 
estingly, seems  to  have  a protective  effect.  Older 
studies  have  shown  that  resumption  of  smoking 
after  cessation  caused  preexisting  ulcers  to  heal 
within  a few  days.9  One  recent  small  study  showed 
that  nicotine  gum  caused  ulcer  healing  and  pre- 
vention when  taken  for  1 month,  and  patients  re- 
lapsed upon  discontinuation  of  the  gum.10  It  has 
been  postulated  that  this  protective  effect  is  due 
to  the  keratinizing  action  of  nicotine  on  the  oral 
mucosa. 

One  of  the  most  interesting  areas  of  recent 
study  involves  the  investigation  of  a possible  im- 
mune mechanism.  Immunopathologic  studies 
have  shown  abnormal  expression  of  major  histo- 
compatibility complex  antigens  on  epithelial  cells 
and  nonspecific  deposition  of  immune  complexes 
in  patients  with  RAS.  Also,  the  presence  of  abnor- 
mal lymphocyte  subpopulations  and  increased 
activity  of  antibody-dependent  cytotoxic  cells  have 
been  documented  in  patients  during  remission  and 
activation  of  disease.  In  genetically  predisposed 
people,  unidentified  antigens  may  trigger  changes 
in  local  lymphocyte  subpopulations.  This,  in  turn, 
may  result  in  an  autoimmune  reaction  against  tar- 
geted epithelial  cells.  The  exact  antigen  triggers  are 
not  yet  clear.  There  are  those  who  find  fault  with 
this  theory,  however,  given  that  the  disease  is  in- 


J La  State  Med  Soc  VOL  1 52  January  2000  1 1 


termittent,  is  generally  mild  and  self  limiting,  and 
does  not  reliably  respond  to  immunomodulating 
drugs.11 

DIAGNOSIS 

History  taking  and  physical  examination  are 
usually  all  that  is  required  to  make  the  diagnosis. 
The  typical  presentation  and  appearance  are  as 
discussed  above.  Key  points  that  will  help  to  elimi- 
nate other  disorders  are  that  the  lesions  will  never 
have  gone  through  a vesicular  stage  and  will  never 
have  any  crusting.  Patients  may  report  triggering 
factors,  such  as  stress,  trauma,  or  certain  foods.  The 
examination  will  show  typical  appearing  shallow 
ulcers  anywhere  in  the  mouth  except  for  the  hard 
mucosa  (ie,  hard  palate  and  attached  gingiva). 
With  these  findings,  it  is  often  appropriate  to  ini- 
tiate treatment  without  any  further  workup. 

Diseases  that  can  be  easily  confused  with  RAS 
include  herpetic  gingivostomatitis  and  herpangina. 
Herpetic  gingivostomatitis  may  occur  primarily  or 
secondarily.  Primary  infection  usually  occurs  in 
young  patients  and  is  associated  with  systemic 
symptoms.  Vesicles  will  appear  anywhere  in  the 
mouth,  including  the  hard  mucosa,  and  will 
progress  to  ulcers  that  crust.  Secondary  herpetic 
infection  is  characterized  by  lesions  that  occur  only 
on  the  hard  mucosa  and  tend  to  recur  in  the  same 
spot.  In  most  patients  these  are  benign  and  self- 
limiting,  but  antiviral  drugs  may  shorten  the 
course.  Herpangina  is  caused  by  the  Coxsackie  A 
virus  and  generally  occurs  in  children  less  than  10 
years  old.  Affected  children  develop  systemic 
symptoms  48  hours  prior  to  developing  papulove- 
sicular lesions  of  the  tonsils  and  uvula.  Generally, 
supportive  therapy  is  all  that  is  required  for  her- 
pangina. 

Patients  with  oral  lesions  whose  appearance 
is  not  consistent  with  RAS  or  with  lesions  that  ap- 
pear to  be  RAS  major  may  require  further  investi- 
gation for  diagnosis.  Often  a biopsy  is  helpful.  Dis- 
eases such  as  pemphigus  vulgaris,  benign  mucosal 
pemphigoid,  lichen  planus,  and  of  course  squa- 
mous cell  carcinoma  can  all  present  with  oral  le- 
sions but  these  lesions  will  not  have  the  typical 
small,  round,  shallow  appearance  of  ulcers  due  to 
RAS. 

There  are  several  systemic  diseases  that  may 
involve  oral  ulcers  that  are  clinically  similar  to  or 
identical  to  those  due  to  RAS.  When  evaluating 


RAS  patients,  these  should  be  kept  in  mind. 
Bechet's  disease  is  a multisystemic  disorder  that 
tends  to  affect  males  of  Mediteranean,  Middle  East- 
ern, or  Japanese  descent.  These  patients  present 
with  the  classic  triad  of  aphthous  ulcers,  genital 
ulcers,  and  uveitis  or  conjunctivitis.  The  oral  ul- 
cers may  be  treated  in  the  same  manner  as  those 
not  associated  for  Bechet's  disease,  but  these  pa- 
tients need  referral  for  systemic  treatment  as  well.4 
Patients  with  HIV  or  AIDS  may  present  with  a 
myriad  of  oral  lesions.  Aphthous  ulcers  have  been 
reported  with  increased  frequency  in  patients  with 
CD4+  counts  below  100. 

RAS  may  require  a biopsy  in  these  patients 
and  treatment  may  be  less  successful.  Several  stud- 
ies have  shown  an  association  between  RAS  and 
gastrointestinal  diseases.4  A subset  of  patients  with 
celiac  sprue  will  have  RAS  and  their  disease  will 
get  better  with  treatment  for  their  sprue.  Likewise, 
a subset  of  patients  with  Crohn's  disease  will  have 
RAS  that  responds  to  treatment  of  the  bowel  dis- 
ease. Some  patients  with  vitamin  deficiencies  such 
as  iron  and  B vitamins  will  have  RAS  that  responds 
to  vitamin  replacement  therapy.7  Some  children 
will  get  aphthous  ulcers  in  conjunction  with  the 
PFAPA  syndrome  (Periodic  Fever,  Aphthous  ul- 
cer, Pharyngitis,  and  cervical  Adenitis).12  Most  RAS 
patients,  however,  will  be  healthy  with  no  sign  of 
associated  disease. 

MANAGEMENT 

Goals  in  management  of  this  disease  reflect 
that  the  disease  is  generally  mild  and  self-limit- 
ing, and  that,  currently,  there  is  no  treatment  that 
is  widely  believed  to  be  curative.  Therefore,  treat- 
ments that  reduce  pain  and  maintain  function  dur- 
ing attacks,  or  that  reduce  the  severity  and  fre- 
quency of  recurrent  attacks,  are  considered  suc- 
cessful. Identification  and  avoidance  of  precipitat- 
ing factors  may  be  more  helpful  for  some  patients 
than  others,  and  to  this  end  an  "ulcer  diary"  may 
be  helpful.  Medical  treatments  used  for  this  gen- 
erally benign  disease  should,  of  course,  not  be  as- 
sociated with  more  morbidity  than  the  disease  it- 
self. 

Treatment  options  can  generally  be  broken 
down  into  palliative  treatments  and  those  that  may 
truly  alter  the  course  of  the  disease.  Palliative  medi- 
cations are  generally  applied  topically.  Topical 
medicines  that  relieve  pain  temporarily  will  allow 


1 2 J La  State  Med  Soc  VOL  1 52  January  2000 


patients  to  comfortably  eat,  and  many  of  these  are 
available  over  the  counter.  Preparations  which 
contain  benzocaine,  diclonine  HC1,  or 
benzydamine  HC1  are  very  effective.  Patients  with 
multiple  lesions,  or  lesions  that  are  not  easily 
within  reach,  may  be  treated  with  a solution  con- 
taining 2%  viscous  lidocaine,  Kaopectate,  and 
benadryl.  This  solution  can  be  mixed  by  pharma- 
cists and  combines  an  anesthetic  with  a protective 
coating  agent.  Patients  should  be  advised  that 
swallowing  this  solution  is  usually  unnecessary 
and  will  likely  cause  drowsiness.13 

A large  number  of  therapeutic  modalities  have 
been  described  for  this  disorder.  Topical  caustic 
agents,  such  as  hydrogen  peroxide,  phenol,  and 
silver  nitrate,  have  been  used  for  some  time  but 
data  regarding  success  using  these  agents  is  lim- 
ited to  anecdotal  reports.  Topical  antimicrobials 
have  been  used  for  some  time.  Antiseptic  mouth- 
washes, such  as  chlorhexidine  gluconate  and 
Listerine,  do  seem  to  have  a beneficial  effect  on 
both  the  duration  and  the  frequency  of  outbreaks 
if  used  regularly  in  susceptible  patients.14  Topical 
application  of  tetracycline  250  mg/ 30  cc  4-6  times 
daily  for  4-5  days  also  has  been  shown  to  possibly 
reduce  the  duration  and  severity  of  an  outbreak.15 
This  tetracycline  elixir  is  no  longer  available  from 
pharmacies,  however,  and  would  have  to  be  mixed 
up  by  patients  using  capsules  and  water. 

Many  practitioners  currently  feel  that  the 
mainstay  of  treatment  of  this  disorder  is  topical 
steroid  application.  Several  different  formulations 
are  available.  Triamcinolone  0.1%  in  dental  paste 
can  be  applied  directly  to  lesions  4 times  daily,  with 
the  last  application  at  bedtime.16  Patients  must  be 
instructed  not  to  eat  or  drink  for  1 hour  after  each 
application  and  the  medication  should  be  used  for 
4-5  days  or  until  the  lesion  begins  to  heal.  This 
medication  can  be  applied  at  the  prodromal  stage 
and  may  prevent  or  abort  an  outbreak.  If  patients 
have  multiple  lesions  or  lesions  that  cannot  be 
reached,  triamcinolone  0.1%  in  an  aqueous  base 
can  be  swished  around  the  mouth  4 times  daily.17 

Beclomethasone  spray  has  also  been  shown 
to  be  successful  in  treating  multiple  ulcers  or  those 
that  are  hard  to  reach.18  As  oral  candidiasis  has 
been  reported  in  patients  using  sprays  and  solu- 
tions, prophylaxis  with  antifungal  agents  should 
be  considered  in  these  patients.  If  patients  have  an 
especially  large  number  of  lesions  or  long  dura- 


tion of  outbreaks,  a "burst  regimen"  of  systemic 
steroid  treatment  may  be  prescribed  in  addition 
to  topical  treatment.1  Patients  may  be  given  pred- 
nisone 40  mg  qd  x 5 days  and  then  20  mg  qod  x 5 
days.  The  success  of  steroid  therapy  lends  support 
to  the  theory  that  the  disorder  has  an  autoimmune 
component. 

Other  immunotherapeutic  regimens  are  being 
investigated  but  are  not  widely  accepted  yet. 
Levamisole  is  an  immunomodulator  which  seems 
to  reduce  healing  time  and  reduce  the  number  of 
ulcers.19  It  does  take  several  months  of  treatment 
to  achieve  this  effect  however,  and  side  effects  may 
include  nausea,  hyperosmia,  dysgeusia,  and 
agranulocytosis.8 

Azathioprine  and  colchicine  have  shown  vari- 
able success  in  recalcitrant  cases,  but  the  lesions 
usually  recur  upon  discontinuation  of  the  drug.4 
Thalidomide  has  been  shown  to  produce  healing 
of  major  aphthae  and  to  improve  eating  ability  in 
affected  HIV  patients.  Due  to  side  effects  such  as 
peripheral  neuropathy,  the  use  of  this  drug  is  gen- 
erally limited  to  the  HIV  population  whose  lesions 
produce  severe  pain,  impair  oral  intake,  and  are 
refractory  to  other  treatments.20 

CONCLUSIONS 

Although  most  patients  who  present  with  a 
complaint  of  recurrent  mouth  ulcerations  will  have 
RAS  minor,  it  is  important  to  rule  out  other  disor- 
ders such  as  Bechet's  disease,  herpes  simplex,  li- 
chen planus,  etc.  This  is  generally  accomplished 
with  an  adequate  history  and  physical.  Patients 
with  lesions  not  typical  of  RAS  may  require  a bi- 
opsy for  diagnosis.  Patients  with  systemic  symp- 
toms may  need  further  laboratory  work-up  or  re- 
ferral to  the  appropriate  specialist.  Although  RAS 
is  generally  mild  and  self-limiting,  it  can  be  highly 
uncomfortable  and  frustrating  for  affected  patients. 

Many  patients  may  have  been  told  that  there 
are  no  effective  treatments  for  this  disorder,  but 
this  is  a misconception.  Although  there  is  no  cure, 
there  are  a number  of  regimens  that  may  signifi- 
cantly improve  the  patient's  symptoms  during  an 
outbreak.  Patients  may  often  even  be  taught  to  treat 
themselves  at  the  prodromal  stage  and  therefore 
abort  an  outbreak.  The  etiology  of  this  disorder 
remains  elusive  but  hopefully  will  become  clear 
with  continued  research  into  immunopathologic 
mechanisms. 


J La  State  Med  Soc  VOL  1 52  January  2000  1 3 


REFERENCES 

1.  Embil  JA,  Stephens  RG,  Manuel  RK.  Prevalence  of 
recurrent  herpes  labialis  and  aphthous  ulcers  among 
young  adults  on  six  continents.  Can  Med  Assoc  J 1975; 
113:627-630. 

2.  Ship  II,  Morris  AL,  Durocher  RT,  et  al.  Recurrent 
aphthous  ulcerations  and  recurrent  herpes  labialis  in  a 
professional  school  student  population.  Oral  Surg  Oral 
Med  Oral  Pathol  1960;13:1191-1202. 

3.  Burns  RA,  Davis  WJ.  Recurrent  aphthous  stomatitis.  AFP 
1985;32:99-104. 

4.  Woo  SB,  Sonis  ST.  Recurrent  aphthous  ulcers:  a review 
of  diagnosis  and  treatment.  JADA  1996;127:1202-1213. 

5.  McCartan  BE,  Sullivan  A.  The  association  of  menstrual 
cycle,  pregnancy,  and  menopause  with  recurrent  oral 
aphthous  stomatitis:  a review  and  critique.  Obstet 
Gynecol  1992;80:455-458. 

6.  Rees  TD,  Binnie  WH.  Recurrent  aphthous  stomatitis. 
Derm  Clinics  1996;14:243-256. 

7.  Wray  D,  Ferguson  MM,  Hutcheon  AW.  Nutritional 
deficiencies  in  recurrent  aphthae.  J Oral  Pathol  1978;7:418- 
423. 

8.  Porter  SR,  Scully  C,  Pedersen  A.  Recurrent  aphthous 
stomatitis.  Grit  Rev  Oral  Biol  Med  1998;9:306-321. 

9.  Bookman  R.  Relief  of  canker  sores  on  resumption  of 
cigarette  smoking.  Calif  Med  1960;93:235-236. 

10.  Bittoun  R.  Recurrent  aphthous  ulcers  and  nicotine.  Med 
J Austr  1991;154:471-472. 

11.  Porter  SC,  Porter  SR.  Recurrent  aphthous  stomatitis: 
current  concepts  of  etiology,  pathogenesis  and 
management.  J Oral  Pathol  Med  1989;18:21-27. 

12.  Thomas  KT,  Feder  HM,  Lawton  AR,  et  al.  Periodic  fever 
syndrome  in  children.  } Pediatr  1999;135:15-21. 

13.  Carpenter  WM,  Silverman  S Jr.  Over-the-counter 
products  for  oral  ulcerations.  J Calif  Dent  Assoc 
1998;26:199-201 

14.  Meiller  TF,  Kutcher  MJ,  Overholser  CD,  et  al.  Effect  of 


an  antimicrobial  mouth  rinse  on  recurrent  aphthous 
ulcerations.  Oral  Surg  Oral  Med  Oral  Pathol  1991;72:425- 
429. 

15.  Graykowski  EA,  Kingman  AK.  Double-blind  trial  of 
tetracycline  in  recurrent  aphthous  ulceration.  J Oral 
Pathol  1978;7:376-382. 

16.  Graykowski  EA,  Hooks  JJ.  Treatment  of  recurrent 
aphthous  ulcerations.  J Oral  Pathol  1978;7:439-440. 

17.  Vincent  SD,  Lilly  GE.  Clinical,  historic,  and  therapeutic 
features  of  aphthous  stomatitis:  literature  review  and 
open  clinical  trial  employing  steroids.  Oral  Surg  Oral  Med 
Oral  Pathol  1992;74:79-86. 

18.  Thomas  AC,  Nolan  A,  Lamey  P-J.  Aphthous  oral 
ulceration:  a double  blind  crossover  study  of 
beclomethasone  diproprionate  aerosol  spray.  Scott  Med 
J 1990;34:531-532. 

19.  Sun  A,  Chiang  CP,  Chiou  PS,  et  al.  Immunomodulation 
by  levamisole  in  patients  with  recurrent  aphthous  ulcers 
or  oral  lichen  planus.  J Oral  Pathol  Med  1994;23:172-177. 

20.  Jacobson  JM,  Spritzler  J,  Fox  L,  et  al  and  the  National 
Institute  of  Allergy  and  Infectious  Diseases  AIDS  Clinical 
Trials  Group.  Thalidomide  for  the  treatment  of 
esophageal  aphthous  ulcers  in  patients  with  human 
immunodeficiency  virus  infection.  J InfDis  1999;180:61- 
67. 


Dr  Murray  is  a resident  physician  in  the  Department  of  Otolaryngology 
at  Tulane  University  Medical  Center  in  New  Orleans,  Louisiana. 

Dr  Amedee  is  a Professor  and  Chair  of  the  Department  of  Otolaryngology 
at  Tulane  University  Medical  Center  in  New  Orleans,  Louisiana. 


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RADIOLOGY  CASE  OF  THE  MONTH 


RIGHT  UPPER  QUADRANT  PAIN 
AND  PALPABLE  MASS 


Maria  Calimano,  MD;  Robert  Perret,  MD;  Harold  Neitzschman,  MD 


This  is  a 52-year-old  woman  who  presented  to  the  E.R.  with  right  upper  quadrant  pain  and  a palpable 
mass  on  physical  examination. 


Figure  1.  Sagittal  ultrasound 
the  right  lobe  of  the  liver. 


image 


through 


Figure  2.  Contrast  enhanced,  early  phase  CT 
scan  image  through  the  upper  abdomen. 


What  is  your  diagnosis? 
Elucidation  is  on  page  17. 

1 6 J La  State  Med  Soc  VOL  1 52  January  2000 


Figure  3.  Contrast  enhanced,  delayed  phase  CT  scan  image 
through  the  upper  abdomen. 


Radiology  Case  of  the  Month 
Presentation  is  on  page  16. 

RADIOLOGIC  DIAGNOSIS— Hemangioma  of  the  liver 
PATHOLOGIC  DIAGNOSIS— Same 


INTERPRETATION  OF  IMAGING 

Figure  1 demonstrates  an  approximately 
11x10  cm,  well  demarcated,  heterogeneously 
echogenic  mass  in  the  right  lobe  of  the  liver.  Fig- 
ure 2 demonstrates  the  same  mass,  which  shows 
nodular-globular  peripheral  enhancement  on  early 
contrast  phase.  In  Figure  3 we  see  how  the  areas 
of  contrast  enhancement  become  confluent  as  the 
tumor  fills  centripetally. 

DISCUSSION 

Hemangiomas  are  considered  the  most  com- 
mon benign  neoplasm  of  the  liver,  occurring  in 
15%  to  20%  of  autopsy  studies.  They  are  typically 
asymptomatic,  can  be  single  or  multiple,  3 cm  to  4 
cm  in  diameter,  most  frequently  occurring  in  the 
right  hepatic  lobe,  and  often  subcapsular.  There  is 
a significant  female  predominance  of  5:1  over  male 
occurrence.  Though  usually  detected  incidentally, 
patients  may  present  for  evaluation  of  acute  or 
chronic  abdominal  complaints  secondary  to  rup- 
ture or  mass  effect  caused  by  large  tumors.  These 
large  tumors,  greater  than  8 cm  to  10  cm  are  re- 
ferred to  as  giant  cavernous  hemangiomas,  as  in 
the  case  being  presented. 

Histologically,  hemangiomas  are  composed  of 
large  capillary  channels  filled  with  blood  or  lymph. 
In  the  liver  these  channels  are  lined  by  a layer  of 
endothelial  cells  without  bile  ducts  and  are  sepa- 
rated by  fibrous  septae.1  Hepatic  hemangiomas  can 
demonstrate  fibrosis,  calcifications,  or  hemor- 
rhage. 

Diagnosis  of  hepatic  hemangiomas  on  imag- 
ing studies  is  usually  not  difficult  as  they  have  typi- 
cal appearances  on  ultrasound,  CT,  and  MRI.  On 
ultrasound,  hemangiomas  most  commonly  appear 
as  well  delineated,  uniformly  hyperechoic  masses, 
often  with  some  acoustic  enhancement.  Larger  tu- 
mors are  often  heterogeneous  due  to  necrosis, 
thrombosis,  and  fibrosis  (Figure  1). 

CT  scan  evaluation  should  include  pre-con- 
trast as  well  as  early  phase  post-contrast  and  de- 


layed imaging.  On  pre-contrast  images,  hemangio- 
mas appear  as  well-defined  hypodense  masses. 
Following  IV  contrast  injection,  early  contrast 
phase  images  should  demonstrate  nodular-globu- 
lar peripheral  enhancement.2  This  finding  is  the 
most  reliable  sign  that  helps  distinguish  heman- 
giomas from  hepatic  metastases  (Figure  2).  This 
peripheral  nodule-like  enhancement  has  been 
found  to  be  88%  sensitive  and  84%  to  100%  spe- 
cific for  hemangiomas.3  In  the  delayed  phase  of 
CT  imaging,  areas  of  enhancement  become 
confluent  as  the  tumor  fills  centripetally  with  con- 
trast enhancement  persisting  for  20-30  minutes 
(Figure  3).  If  the  lesion  has  fibrosis  or  necrosis  these 
areas  will  remain  hypodense  with  time. 

Both  Tc-99  RBC  scintigraphy  with  SPECT  im- 
aging and  MRI  with  and  without  IV  contrast  have 
also  shown  to  have  very  high  positive  predictive 
value. 

REFERENCES 

1.  Kumar  V,  Cotran  RS,  Robbins  SL.  Basic  Pathology,  5th 
edition.  Philadelphia,  Pa:  WB  Saunders;  1992:301. 

2.  Mergo  PJ,  Ros  PR.  Benign  lesions  of  the  liver.  Radiol 
Clin  North  Am  1998;36:319-331. 

3.  Leslie  DF,  Johnson  CD,  Johnson  CM,  et  al.  Distinction 
between  cavernous  hemangiomas  of  the  liver  and 
hepatic  metastases  on  CT:  value  of  contrast  enhancement 
patterns.  AJR  1995;164:625-629. 


Dr  Calimano  is  Junior  Radiology  Resident  at  Louisiana  State  University 
Health  Services  Center  in  New  Orleans,  Louisiana. 

Dr  Ferret  is  Associate  Professor  of  Radiology  at  Louisiana  State 
University  Health  Services  Center  in  New  Orleans,  Louisiana. 

Dr  Neitzschman  is  Associate  Professor  of  Radiology,  Orthopedics,  and 
Nuclear  Medicine  at  Louisiana  State  University  Health  Services  Center 

in  New  Orleans,  Louisiana. 


J La  State  Med  Soc  VOL  1 52  January  2000  1 1 


IE  JOURNAL  150  & 100  YEARS  AGO 


JANUARY  1850  AND  1900 

Gustavo  Colon,  MD 


There  is  an  article  on  Apoplexy  of  the  South, 
its  pathology  and  treatment  by  Dr  Samuel 
Cartwright.  He  states  that  there  is  a differ- 
ence in  apoplexy,  which  we  define  today  as  a 
stroke,  but  which  was  defined  at  that  time  as  a brain 
seizure  which  could  either  be  a stroke  or  a seizure 
(fit).  He  defines  the  disease  as  being  a complete  or 
partial  suspension  of  "life  of  relation",  which  had 
two  functions:  one  by  which  impressions  from 
without  reached  the  brain,  that  is,  external  stimuli, 
and  the  other  which  the  brain  exercises  on  the  body, 
the  internal  functions  of  the  brain  on  our  complete 
organic  system. 

The  brain  can  neither  act  nor  be  acted  upon 
except  in  a very  imperfect  manner  when  an  apo- 
plexy occurs.  Both  of  these  orders  of  function  in  a 
healthy  state  are  equivalent  to  each  other  and  both 
require  a proper  degree  of  activity  of  the  circulat- 
ing system  for  performance.  However,  apoplexy 
occurs  when  the  two  orders  of  function  cease  to  be 
equivalent;  in  other  words,  a "super  abundant 
simulation  or  a defect  of  excretory  function".  He 
states  that  the  first  problem  in  constituting  apo- 
plexy is  the  depletion  of  red  and  the  latter  deple- 
tion of  black  blood,  and  that  the  one  connected  with 


red  blood  is  arterial  reaction  and  the  other  one  is 
secondary  to  venous  congestion  in  the  brain  and 
that  these  arise  not  from  the  brain  itself  but  as  a 
consequence  of  a defect  in  the  secretory  and  ex- 
cretory functions  of  the  body  itself  and  generally 
in  the  South  or  in  warmer  weather.  The  best  cure 
is  to  awaken  all  the  absorbing  and  secretory  and 
excretory  glands  from  their  dormant  state  into  in- 
creased activity  particularly  those  glands  and  fol- 
licles in  the  immediate  vicinity  of  the  congested 
brain.  The  congestion  itself  occurs  because  of  the 
increased  action  in  the  excretory  system  and  this 
is  evidenced  in  the  symptoms  that  occur  in  apo- 
plexy or  a seizure  in  which  copious  amounts  of 
excretions  of  viscid  mucus  occurred  during  the 
apoplexy  fit  with  abundant  secretions  of  the  lar- 
ynx, trachea,  and  esophagus  that  require  a great 
deal  of  suction  to  remove  and  can  occasionally 
cause  death  by  obstructing  the  respiratory  organs. 
As  a matter  of  fact,  the  Dominican  Friars  of  the 
middle  ages  had  an  elixir  "antapoplexia"  which 
was  nothing  more  than  a combination  of  power- 
ful antiphlogistic  ingredients  calculated  to  de- 
crease the  inactivity  of  the  trachea,  larynx,  esopha- 
gus, and  naris  and  to  increase  the  secretion  of  their 


1 8 J La  State  Med  Soc  VOL  1 52  January  2000 


mucous  membranes.  In  order  to  excite  further  se- 
cretions, it  was  felt  the  remedy  had  total  success 
in  curing  the  disease  in  all  of  southern  Europe. 
They  advocated  the  following  treatment  for  apo- 
plexy: "2  teaspoons  of  table  salt,  2 teaspoons  of 
mustard  flour,  1 teaspoon  of  ipecac,  and  1 teaspoon 
of  tincture  of  a gum  resin  in  a tumbler  of  warm  or 
cold  water".  The  more  disgusting  the  medicine  the 
better  it  is  because  it  loosens  the  tenacious  phlegm 
adhering  to  the  throat  and  air  patches  and  creates 
further  secretions.  The  pungency  of  the  mustard 
is  all  important  for  the  same  purpose.  The  throat 
is  so  choked  up  with  mucus  and  phlegm  that  swal- 
lowing anything  is  impossible  but  the  mixture  does 
create  good  without  being  swallowed,  its  mere 
presence  in  the  mouth  loosens  the  tenacious 
phlegm  adhering  to  the  back  of  the  throat,  caus- 
ing it  to  pour  out  of  the  mouth,  and  arrests  the 
stertorous  breathing  caused  by  the  phlegm  in  the 
throat  which  enables  the  patient  to  breathe  easier 
by  creating  further  secretions  and  thinning  out  the 
thick  phlegm  that  they  have  secondary  to  the  sei- 
zure or  apoplexy. 

However,  it  is  better  for  the  patient  to  swal- 
low the  mixture  until  he  vomits  or  it  acts  on  the 
bowels.  It  should  be  forced  into  the  throat  by  hold- 
ing the  mouth  open  with  a spoon  and  into  this  the 
mixture  should  be  poured  with  another  spoon. 
When  it  falls  down  the  root  of  the  tongue,  it  causes 
a heating,  strangling  kind  of  motion  made  by  the 
patient;  then  he  should  be  turned  a little  on  the 
side  to  enable  the  loosened  phlegm  and  the  in- 
creased secretions  to  run  out  the  mouth.  But  soon 
the  patient  should  be  placed  on  his  back  again  with 
the  head  a little  elevated  to  get  more  medicine. 

While  this  is  going  on,  hot  water  with  mus- 
tard should  be  poured  time  after  time  on  the 
patient's  feet  and  hands,  and  a flannel  shirt,  rung 
out  of  very  hot  water,  doubled  up  in  a large  ball 
and  wrapped  in  a dry  flannel,  should  be  applied 
over  the  stomach  and  bowels  and  frequently  re- 
newed as  hot  as  the  hands  can  bear  it.  A great  deal 
of  phlegm  and  a ropy,  white,  egg-looking  sub- 
stance will  be  thrown  up  and  the  patient  will  get 
relief.  A chamomile  may  be  given  to  encourage  the 
vomit.  If  the  head  is  hot  and  the  face  red,  then  the 
head  and  face  should  frequently  be  wet  with  cold 
water.  When  the  skin  gets  hot,  the  pulses  rise  and 
the  face  is  flushed,  bleeding  from  the  arm  should 
be  resorted  to  at  that  time  but  it  is  a very  danger- 


ous expedient  at  this  point  and  should  only  be  re- 
sorted to  as  a last  measure.  After  the  vomiting,  a 
20-grain  dose  of  chamomile  floating  on  a spoon  of 
water  should  be  given  along  with  a stimulating 
enema  to  move  the  bowels.  Subsequent  treatment 
consists  of  little  more  than  a gruel  diet,  a little  salt, 
and  very  small  doses  of  sweet  alcoholic  spirits  to 
act  on  the  kidneys.  If  the  patient  can  be  made  to 
vomit,  he  almost  invariably  regains  his  facilities. 
Some  physicians  have  theoretical  fears  of  vomit- 
ing but  it  never  does  mischief  to  the  head  in  any 
case  except  where  there  is  great  heat  on  the  whole 
surface  and  a flushed  face.  In  that  case,  bleeding 
and  vomiting  at  the  same  time  may  be  well  used 
together.  The  means  that  have  been  recommended 
should  be  well  fixed  in  the  mind  beforehand  as  to 
what  needs  to  be  done.  Everything  should  be  done 
in  conjunction  in  order  to  ameliorate  the  apoplec- 
tic event.  He  states  finally  that  the  greatest  num- 
ber of  cases  of  apoplexy  in  the  South  occur  in  the 
summer  months.  In  a cold  climate,  apoplexy  oc- 
curs because  of  a surplus  of  arterial  blood  in  the 
cerebral  vessels  whereas  in  a hot,  damp  climate 
the  reverse  is  the  case.  There  is  an  accumulation  of 
blood  in  the  venous  system  and  the  treatment 
which  is  recommended  is  to  increase  the  secretion 
and  minimize  the  congestion  within  the  venous 
system  particularly  around  the  head  and  neck  area. 

The  January  1900  issue  of  The  Journal  has 
some  points  of  interest  about  different  diseases  and 
how  they  should  be  treated.  Heart  disease  from 
an  obstetric  point  of  view  is  briefly  summarized 
as  follows.  (1)  A woman  having  a heart  lesion 
which  is  compensated  should  not  be  prevented 
from  marrying.  (2)  Abortion  should  not  be  induced 
on  a woman  with  disease  unless  her  symptoms  are 
present.  (3)  Premature  labor  should  seldom  or 
never  be  induced  on  account  of  heart  disease.  (4) 
Mitral  stenosis  is  the  most  serious  heart  lesion  dur- 
ing pregnancy  and  labor,  aortic  stenosis  comes  next 
and  then  probably  aortic  incompetency.  Mitral  in- 
sufficiency is  the  least  serious  lesion.  (5)  Treatment 
during  pregnancy — administer  strychnine,  digi- 
talis, cathartics,  and  nitroglycerin,  and  regulate  the 
diet.  (6)  During  labor,  keep  up  the  action  of  digi- 
talis especially  during  the  first  stage;  give  strych- 
nine and  stimulants  if  required  and  chloroform  as 
indicated;  and  as  soon  as  the  first  stage  is  com- 
plete deliver  with  forceps.  (7)  Watch  the  patient 
carefully  during  the  third  stage,  which  is  the  most 


J La  State  Med  Soc  VOL  1 52  January  2000  1 9 


dangerous  time,  and  for  some  days  after. 

There  is  another  list  of  persons  who  should 
not  take  alcohol:  (1)  those  who  have  a family  his- 
tory of  drunkenness,  insanity,  or  nervous  diseases; 
(2)  those  who  have  used  alcohol  in  excess  or  in 
childhood;  (3)  those  who  are  nervous,  irritable,  or 
badly  nourished;  (4)  those  who  suffer  from  inju- 
ries to  the  head,  diseases  of  the  brain,  and  sun 
stroke;  (5)  those  who  suffer  from  great  bodily 
weakness  particularly  during  convalescence  from 
exhausting  diseases;  (6)  anyone  who  engages  in 
exciting  or  exhausting  climates  in  bad  air  and  in 
the  surroundings  of  workshops  and  mines;  (7) 
those  that  are  solitary  and  lonely  and  require 
amusement;  (8)  those  who  have  little  self  control 
either  hereditary  or  acquired;  and  (9)  those  who 
suffer  from  brain  weakness  as  a result  of  senile 
degeneration. 

This  is  how  to  avoid  consumption:  (1)  a gen- 
erous diet  of  nutritious  food;  (2)  free  ventilation 
of  a dwelling  and  sleeping  by  open  windows;  (3) 
adequate  house  heating  in  the  winter;  (4)  boil  all 
milk  and  cream  prior  to  using;  (5)  obtain  8 hours 
of  sleep,  if  not  sound  sleep  contract  hours  to  7 and 
rest  during  the  day;  (6)  if  debilitated  with  weak 
digestion,  rest  in  a recumbent  position  shortly  be- 
fore and  after  meals;  (7)  wear  loose  clothing  espe- 
cially around  the  waist  and  lower  ribs  to  afford 
freedom  of  respiration;  (8)  take  systematic  daily 
exercises  in  the  open  air  or  on  foot;  (9)  if  means 
and  station  in  life  permit,  take  a long  holiday  from 
time  to  time  and  live  during  fine  weather  in  a tent 
in  the  open  air  or  in  a summer  house  for  most  of 
the  day;  and  (10)  if  unemployed,  pursue  a hobby 
to  occupy  the  mind. 

From  the  Department  of  Ear,  Nose  and  Throat 
is  the  following  case  of  vicarious  menstruation 
from  the  ear  which  was  reported  from  Paris.  It 
states  its  subject  was  a 17-year-old  girl  who  for  3 
years  had  been  having  regular  monthly  discharges 
of  blood  from  the  right  ear  lasting  3 or  4 days  and 
accompanied  by  all  of  the  phenomena  associated 
with  menstrual  periods.  The  patient  suffered  with 
headaches,  malaise,  and  slight  tenderness  about 
the  ear  with  each  recurrence  of  hemorrhage.  These 
symptoms  disappeared  upon  its  cessation.  Exami- 
nation of  the  ear  revealed  a perfectly  normal  tym- 
panic membrane  but  a number  of  small  varicose 
vessels  occupied  the  walls  of  the  osseous  portion 
of  the  meatus  which  was  the  site  of  the  hemor- 


rhage. The  genital  menstruation  appeared  at  age 
17,  but  the  discharge  from  the  ear,  instead  of  ceas- 
ing, accompanied  the  vaginal  flow,  in  addition  at 
times  associated  with  epistaxis  and  hemorrhage 
from  the  mouth.  The  patient  was  in  good  general 
health  and  presented  no  evidence  of  being  hemo- 
philic or  hysteric.  The  hearing  was  not  materially 
affected.  The  conclusion  is  that  menstruation  from 
the  ear  is  an  extremely  rare  condition,  but  a few 
similar  cases  have  been  reported  in  the  past. 


Dr  Colon  has  a plastic  surgery  practice  in  Metairie,  Louisiana  and  has 
lectured  on  the  history  of  medicine  at  Lousisiana  State  University  School 
Health  Services  Center,  in  New  Orleans,  Louisiana  and  Tulane  University 
School  of  Medicine  in  New  Orleans,  Louisiana. 

The  author  and  The  Journal  welcome  comments  on  the  history  of 

medicine. 


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AIM  HIGH 


HEALTH  PROFESSIONS 


20  J La  State  Med  Soc  VOL  1 52  January  2000 


HOW  CAN  GENETICS  HELP 
IN  THE  MANAGEMENT  OF  OBESITY? 


Theodore  F.  Thurmon,  MD 


Obesity  usually  results  from  unwanted  variations  in  metabolism.  Inadequate  neurotransmission,  ther- 
mogenesis, or  acylation  underlie  about  90%  of  cases.  These  are  complex,  weakly  heritable,  polygenic 
traits.  Mutations  in  major  gene  loci  cause  another  5%  of  cases,  and  still  another  5%  of  cases  are  due  to 
gluttony.  Careful  observation  can  help  define  the  type  of  obesity.  All  forms  are  associated  with  excess 
mortality  and  require  lifelong  episodic  or  continuous  management.  Management  centers  around  diet, 
exercise,  behavior  therapy,  and  life-style  counseling.  Serotonin  agonists  and  serotonin  uptake  inhibitors, 
as  well  as  alternative  therapies  like  phototherapy  and  5-hydroxytryptophan  are  worthwhile  for  neurotrans- 
mitter inadequacy,  except  in  children  and  pregnant  women.  When  thermogenesis  is  inadequate,  intake 
may  be  normal  and  weight  reduction  may  require  subnormal  intake.  Some  degree  of  obesity  may  be 
required  for  optimal  health  in  patients  with  inadequate  acylation.  In  some  Mendelian  syndromes,  obe- 
sity may  balance  a metabolic  error,  and  weight  reduction  may  restore  metabolic  imbalance. 


The  body  mass  index  or  BMI  (weight/ 
height)  is  a working  standard  for  defin- 
ing obesity.  A working  standard  for  expres- 
sion of  the  adverse  effects  of  obesity  is  the  all-cause 
excess  mortality.  Older  definitions  assumed  a sort 
of  constancy  in  BMI  and  in  its  relationship  to  mor- 
tality. More  recent  data  clearly  show  changes  in 
both  with  age.  The  same  BMI  is  associated  with 
greater  excess  mortality  at  younger  ages.  Percen- 
tile distributions  of  BMI  and  age  are  available,1  so 
there  remains  little  reason  to  use  ill-fitting  assump- 
tions of  constancy.  The  90th  percentile  of  the 


NHANES  II  BMI  for  age2  closely  matches  the  dis- 
tribution of  excess  mortality.  For  purposes  of  this 
discussion,  it  will  be  used  as  the  definition  of  obe- 
sity. 

Careful  studies  have  not  revealed  major  meta- 
bolic defects  as  causes  of  the  majority  of  cases  of 
obesity.  Instead,  there  is  a group  of  relatively  subtle 
metabolic  variations  that  are  easiest  to  recognize 
after  obesity  has  become  established.  These  varia- 
tions can  produce  obesity  rapidly  if  intake  is  pro- 
digiously increased.  More  typically,  they  cause  a 
mild,  long  term,  positive  imbalance  between  food 


J La  State  Med  Soc  VOL  152  January  2000  21 


intake  and  energy  expenditure  that  results  in  obe- 
sity. 

Prior  to  the  Genome  Project,  variations  in  neu- 
rotransmission, thermogenesis,  and  acylation  were 
found  to  be  important  to  the  pathogenesis  of  obe- 
sity. The  Genome  Project  diverted  research  efforts 
into  searching  for  the  culprit  genes.  Numbers  of 
those  genes  have  been  found  but  none  that  ac- 
counts for  a significant  proportion  of  cases  of  obe- 
sity. Instead,  genetic  aspects  of  most  cases  of  obe- 
sity are  similar  to  those  that  underlie  other  body 
characteristics:  important,  but  not  due  to  identifi- 
able individual  genes. 

Attention  has  now  returned  to  the  pathogen- 
esis of  obesity.  In  the  seminal  work  in  the  1980s, 
the  Wurtman  team  observed  obese  subjects  in  a 
closed  environment.3  That  work  provided  impor- 
tant leads  to  the  etiology  of  obesity.  By  following 
one  of  the  leads,  that  team  substantiated  the  neu- 
rotransmitter mechanism.  Recent  work  has  been 
summarized  by  Jeanrenaud  et  al.4  Liebel  et  al  docu- 
mented the  acylation  mechanism.5  A description 
of  a current  project  and  a comprehensive  bibliog- 
raphy of  recent  work  in  acylation  are  provided  by 
Guo  et  al.6  Jequier7  promoted  work  on  the  thermo- 
genesis mechanism  in  humans.  Recent  work  in 
thermogenesis  is  described  by  Schrauwen  et  al.8 
Rare  cases  of  variations  in  these  mechanisms  may 
be  due  to  major  genes.  Major  genes  have  also  been 
found  to  cause  other  problems  that  lead  to  rare 
cases  of  obesity.9 

Metabolic  variations  that  underlie  obesity  may 
predispose  to  ill  health  when  famine  renders  food 
in  short  supply.  Persons  with  a neurotransmitter 
problem  may  suffer  insomnia  and  chronic  fatigue. 
Persons  with  a thermogenesis  problem  may  tend 
toward  hypothermia.  Those  with  an  acylation 
problem  may  have  hypotension  and  immunode- 
ficiency. During  famine,  the  proportion  of  persons 
who  are  asthenic,  sickly,  and  short-lived  due  to 
those  problems  may  approximate  the  proportion 
of  obese  persons  when  food  is  plentiful.  Effects  of 
rare  major  genes  for  obesity  may  also  result  in  poor 
health  during  deprivation. 

POLYGENIC  OBESITY 

Investigators  of  obesity  often  work  under  the 
assumption  of  homogeneity.  Heterogeneity  among 
obese  patients  was  documented  by  Jequier.  He 
found  that  about  one  third  of  obese  patients  had 


inadequate  thermogenesis.  Inclusion  of  other  pa- 
tients in  previous  studies  had  hampered  discern- 
ment of  the  importance  of  inadequate  thermogen- 
esis. The  Wurtman  team  found  about  the  same  fre- 
quency of  inadequate  neurotransmission.  Studies 
of  heterogeneity  of  inadequate  acylation  allow  a 
similar  estimate  of  its  frequency.  Even  within  each 
category,  there  is  heterogeneity,  as  the  degree  of 
inadequacy  may  vary  from  mild  to  severe. 

Not  all  persons  with  these  problems  are  obese. 
Frugal  eating  habits  and  an  active  life  style  arrived 
at  for  reasons  other  than  weight  control  may  re- 
sult in  normal  weight.  If  that  equilibrium  is  dis- 
turbed, obesity  may  then  occur  in  a person  who 
seemingly  had  no  problem  previously.  The  fre- 
quency of  these  metabolic  problems  suggests  that 
ready  availability  of  highly  nutritious  foods  com- 
bined with  societal  promotion  of  poorly-controlled 
eating  habits  and  a sedentary  life  style  could  even- 
tually push  the  frequency  of  obesity  as  high  as  50%. 

Combined  defects  are  evident  in  numbers  of 
reports  but  there  has  been  no  study  to  determine 
their  frequency.  These  are  such  common  problems 
that  many  obese  patients  may  have  combinations 
of  one  or  more  of  them.  Other  metabolic  problems 
that  may  be  exaggerated  in  Mendelian  disorders, 
like  fat  storage,  insulin  effects,  hormone  effects, 
and  energy  expenditure,  are  not  clearly  separate 
from  these.  Some  characteristics  of  obesity,  such 
as  body  fat  distributions,  have  more  to  do  with 
the  consequences  of  obesity  than  with  its  acquisi- 
tion. 

Prescriptive  feeding  of  children  will  usually 
delay  manifestation  of  these  problems  until  eman- 
cipation, as  significant,  long-term  excessive  intake 
is  required.  De  facto  emancipation  may  occur  quite 
early  for  latch-key  children.  When  obesity  occurs 
in  childhood,  it  has  the  same  characteristics  as  in 
adulthood.  However,  except  in  the  case  of  ther- 
mogenesis defects,  the  food  must  be  provided  by 
a caretaker  or  a group  of  caretakers.  Successful 
management  involves  identifying  the  source  of  the 
food. 

Neurotransmission 

The  central  theme  is  that  metabolites  of  food 
may  act  as  signal  molecules  or  may  stimulate  pro- 
duction of  signal  molecules  that  ordinarily  reach 
the  brain  via  the  blood  stream  and  staunch  further 
eating.  If  that  process  is  blunted,  obesity  is  likely. 


22  J La  State  Med  Soc  VOL  1 52  January  2000 


Intake  is  excessive.  Quests  for  just  the  right  food 
to  satisfy  the  appetite  are  typical  of  this  form  of 
obesity.  Nocturnal  hyperphagia  may  be  a prereq- 
uisite for  sleep,  and  lack  of  it  may  produce  sleep 
disorder  and  chronic  fatigue.  The  plasma  tryp- 
tophan/large neutral  amino  acids  ratio,  which 
normally  rises  after  a carbohydrate  meal,  does  not 
change  in  these  patients.  That  test  is  not  available 
for  clinical  use.  Serotonin  and  similar  neurotrans- 
mitters  are  at  the  end  of  the  signaling  pathway. 
Maneuvers  that  promote  serotonergic  activity  in 
the  brain  normalize  food  intake. 

Acylation 

Most  of  the  energy  derived  from  food  is  stored 
in  fat  cells  as  triglyceride.  The  main  way  in  which 
this  stored  energy  can  be  utilized  is  through  lipoly- 
sis  into  fatty  acids  that  are  released  into  the  blood. 
An  acylation  mechanism  within  the  fat  cell  nor- 
mally recycles  about  half  of  the  fatty  acids  back 
into  triglycerides  before  they  reach  the  blood.  De- 
pression of  that  mechanism  leads  to  excessive  re- 
lease of  fatty  acids.  Depletion  of  intracellular  trig- 
lyceride stimulates  hunger  and  the  resultant  ad- 
ditional intake  causes  obesity.  Intake  is  excessive. 
Obsession  with  food  may  be  a marker  of  this  type 
of  obesity.  Affected  persons  may  have  gourmet 
tendencies.  Documentation  of  postprandial  fatty 
acid  release  is  difficult  because  the  process  is  un- 
evenly distributed  throughout  the  body.  Signifi- 
cant weight  reduction  may  lead  to  low  thyroid 
function,  leukopenia,  hypotension,  bradycardia, 
amenorrhea,  and  malaise. 

Thermogenesis 

About  15%  of  bodily  energy  expenditure  nor- 
mally produces  heat,  mainly  through  oxidation  of 
fat  during  cellular  respiration.  If  this  process  is 
inadequate,  the  energy  is  stored  as  fat  instead,  and 
obesity  results.  Typically,  food  preferences  are  not 
unusual,  and  intake  is  normal.  This  type  of  obe- 
sity may  be  typical  of  isolated  populations  in  hot 
climates  where  the  food  supply  is  marginal. 

In  animal  models,  thermogenesis  is  a function 
of  brown  adipose  tissue  and  can  be  measured  over 
body  parts  where  brown  adipose  tissue  is  local- 
ized. Humans  have  additional  steps  in  adipose  tis- 
sue development  that  disperse  the  brown  adipose 
tissue.  The  distribution  is  uneven  throughout  the 


body  and  different  in  different  people  so  thermo- 
genesis cannot  be  easily  evaluated.  The  respira- 
tory chamber  is  used  for  research  but  is  impracti- 
cal for  clinical  purposes.  Significant  weight  reduc- 
tion may  lead  to  lowered  basal  metabolic  rate 
(BMR),  cold  intolerance,  poor  stress  responses, 
and,  eventually,  malnutrition. 

GLUTTONY 

In  colonies  maintained  for  research  purposes, 
rats  are  ordinarily  fed  a "chow"  that  is  totally  nu- 
tritionally adequate  but  lacks  attractive  excipients. 
It  is  common  practice  to  keep  a hopper  filled  with 
chow  to  ensure  an  adequate  food  supply.  Despite 
this  excess  of  available  food,  the  rats  do  not  gain 
weight  excessively.  In  cafeteria  diet  experiments, 
new  and  palatable  foods  similar  to  those  in  a caf- 
eteria line  were  provided  to  the  rats  daily.  That 
quickly  and  uniformly  caused  obesity.  Return  to 
the  diet  of  chow  resulted  in  return  to  normal  body 
weight.  Repetitive  experiments  with  the  same  rats 
resulted  in  return  to  normal  weight  each  time,  with 
no  lasting  effects  on  metabolism. 

The  "cafeteria  diet"  rat  is  a model  for  the  prob- 
lem of  gluttony  in  humans.  Rats  have  little  self- 
control  or  judgment,  both  of  which  are  required 
for  weight  control  in  a milieu  of  readily  available, 
palatable  foods.  Patients  affected  by  gluttony  may 
be  deficient  in  these  personality  characteristics  and 
may  exhibit  impulsiveness  and  denial.  They  may 
represent  themselves  as  lovers  of  good,  ordinary 
food.  Intake  is  excessive  but  there  is  no  metabolic 
abnormality.  A genetic  tendency  has  not  been  iden- 
tified but  the  known  heritability  of  personality 
traits  suggests  that  there  may  be  one.  Unlike  in 
other  forms  of  obesity,  weight  reduction  is  rela- 
tively simple  and  safe.  Like  in  other  forms,  relapse 
is  frequent.  Gluttony  probably  accounts  for  about 
5%  of  cases  of  obesity  at  present  but  could  be  ex- 
pected to  rise  in  frequency  if  palatable  food  be- 
comes even  more  available. 

This  type  of  obesity  may  also  be  found  in  pa- 
tients with  more  serious  problems  such  as  psychi- 
atric disorders  and  the  anorexia-bulemia  spectrum. 
In  these  disorders,  standard  obesity  treatment  ap- 
proaches may  have  paradoxical  or  untoward  re- 
sults so  efforts  should  be  made  to  identify  them 
before  embarking  on  a course  of  therapy.  Third 
party  observers  are  invaluable  in  this  regard.  The 


J La  State  Med  Soc  VOL  1 52  January  2000  23 


Table  1 

Typical  Major  Genes  for  Obesity 
(DNA  testing  is  currently  unavailable  for  any  of  them) 

OMIM 

Locus 

Gene,  abbreviation,  inheritance 

Process  causing  obesity 

109690 

5q32 

Beta-2-adrenersic  receptor,  ADRB2,  Autosomal  dominant. 
Decreased  energy  expenditure. 

Decreased  lipolysis 

109691 

8p12 

Beta-3-adrenergic  receptor,  ADRB3,  Autosomal  dominant. 
Decreased  lipolysis. 

Decreased  thermogenesis 

118444 

4p15.2 

Cholecystikin  A receptor,  CCKAR,  Autosomal  dominant. 
Intestinal  motility  disorder. 

Central  hyperphagia 

164160 

7q31 .3 

Leptin,  LEP,  Autosomal  dominant. 

Central  hyperphagia 

155541 

18q22 

Melanocortin  4 receptor,  MC4R,  Autosomal  dominant. 

Central  hyperphagia 

601487 

3p25 

Perioxisome  proliferator  activated  receptor,  gamma,  PPARG, 
Autosomal  dominant.  Insulin  resistance. 

Hyperlipidemia 

176830 

2p23.3 

Proopiomelanocortin,  POMC,  Autosomal  dominant. 
Decreased  energy  expenditure. 

Central  hyperphagia 

162150 

15q15 

Proprotein  convertase  subtilisin/kexin  type  1 , PCSK  1 , 
Autosomal  dominant. 

Impaired  prohormone  processing 

602044 

1 1 ql  3 

Uncoupling  protein  3,  UCP3,  Autosomal  dominant. 

Decreased  thermogenesis 

601007 

1p31 

Leptin  receptor,  LEPR,  Autosomal  recessive. 

Hypothalamic  hyperphagia 

binge  eating  that  is  a hallmark  of  the  anorexia- 
bulemia  spectrum  may  be  difficult  to  differentiate 
from  the  satisfaction-seeking  activities  of  neu- 
rotransmitter inadequacy.  When  it  is  possible  to 
differentiate  the  two,  it  is  usually  on  the  basis  of 
the  more  generalized  disturbance  of  personal  and 
occupational  relationships  that  may  typify  the  an- 
orexia-bulemia  spectrum. 

MAJOR  GENES 

Major  genes  for  obesity  have  been  located  on 
every  chromosome  except  Y.  Nearly  half  have  been 
identified  through  homology  with  genes  of  other 
species.  Those  genes  are  not  usually  independent 
causes  of  actual  cases  of  obesity  in  humans  but  they 
provide  vital  clues  to  the  genetic  background  of 
obesity.  Some  of  their  effects  include  decreased 
energy  utilization,  excessive  fat  storage,  hyper- 
phagia,  impaired  prohormone  processing,  insulin 
resistance,  and  decreased  thermogenesis.  Some  of 
the  variations  are  similar  to  those  of  polygenic 
obesity  but  none  of  these  genes  has  been  associ- 


ated with  it.  McKusick10  provides  extensive  docu- 
mentation. A free  online  version  is  more  current 
(OMIM).11  Also  documented  in  OMIM  are  several 
reports  of  single  cases  or  single  families  of  curious 
syndromes  in  which  obesity  may  be  primary. 
OMIM  contains  discussions  and  literature  citations 
about  the  remainder  of  the  disorders  discussed  in 
this  section. 

Most  of  the  major  genes  associated  with  obe- 
sity have  been  discovered  through  rare  families  in 
which  obesity  follows  a Mendelian  inheritance 
pattern:  autosomal  dominant  (inherited  from  an 
affected  parent),  autosomal  recessive  (1/4  of  sibs 
affected,  parents  consanguineous),  or  X-linked 
(brothers,  maternal  uncles,  and  sons  of  maternal 
aunts  affected).  All  are  quite  rare.  Actual  counts 
of  numbers  of  cases  that  have  been  identified  al- 
low an  estimate  that  these  genes,  in  toto,  account 
for  no  more  than  5%  of  cases  of  obesity. 

The  family  genealogy  pattern  is  usually  the 
only  clinical  clue  to  the  presence  of  one  of  these 
genes.  Clinical  use  of  DNA  analysis  for  diagnosis 


24  J La  State  Med  Soc  VOL  1 52  January  2000 


Table  2 

Typical  Syndromes  with  Features  that  Lead  to  Obesity 

OMIM 

Locus 

Gene,  abbreviation,  inheritance 

Process  causing  obesity 

103581 

15q1 1 

Albright  hereditary  osteodystrophy  2, 
AH02,  Autosomal  dominant. 

Hormone  resistance 

103580 

20q13.2 

Albright  hereditary  osteodystrophy, 
AHO,  Autosomal  dominant 

Hormone  resistance 

107730 

2p24 

Apolipoprotein  B,  APOB, 
Autosomal  dominant 

Hyperlipidemia 

139250 

1 7q22 

Growth  hormone  1*,  GH1, 
Autosomal  dominant 

Insulin  resistance  Hyperlipidemia 

144800 

? 

Hyperostosis  frontalis  interna, 
Autosomal  dominant 

Hyperprolactinemia 

184700 

? 

Polycystic  ovary  syndrome  1,  PCOI, 
Autosomal  dominant. 

Insulin  resistance 

190160 

3p24.3 

Thyroid  hormone  receptor,  beta*, 
THRB,  Autosomal  dominant 

Thyroid  hormone  resistance 

190430 

? 

Triglyceride  storage  disease  - type  II, 
Autosomal  dominant 

Hyperlipidemia 

*DNA  test  available 

is  impractical  at  present.  The  genes  control  diverse 
metabolic  processes  (Table  1).  There  are  no  gener- 
alities such  as  the  most  common  gene,  chromo- 
some, or  metabolic  process.  In  these  syndromes, 
obesity  may  be  a compensatory  mechanism  to  bal- 
ance a metabolic  error.  Weight  reduction  may  re- 
turn the  patient  to  metabolic  imbalance. 

Obesity  is  non-randomly  associated  with  sev- 
eral syndromes  as  a secondary  effect.  In  achondro- 
plasia (OMIM  100800),  there  may  be  decreased 
energy  expenditure  due  to  unusual  body  confor- 
mations. Soft  tissue  growth,  though  normal,  may 
be  out  of  proportion  to  bone  growth,  producing  a 
high  body  mass  index.  Decreased  energy  expen- 
diture may  result  from  the  deformities  of 
acrocephalosyndactyly  III  (Carpenter  syndrome. 
OMIM  201000).  Pain  from  subcutaneous  lipomas 
of  adiposis  dolorosa  (OMIM  103200)  may  result 
in  decreased  activity  and  consequent  decreased 
energy  expenditure.  Choroideremia-deafness-obe- 
sity  (OMIM  303110)  is  an  example  of  a contiguous 
gene  syndrome.  A long  deletion  inactivates  all  of 


the  genes  in  the  neighborhood.  A gene  for  obesity 
may  exist  in  that  area  of  the  X chromosome.  It  is 
curious  that  obesity  is  also  non-randomly  associ- 
ated with  another  eye  disorder,  corneal  dystrophy- 
obesity  (OMIM  122000).  Decreased  vision  may  lead 
to  decreased  activity.  Obesity  in  Cushing  syn- 
drome (OMIM  219080,  219890)  is  well  known  but 
a pathogenic  mechanism  is  unclear. 

A number  of  other  syndromes  that  may  not 
be  considered  " obesity  syndromes"  have  aspects 
that  lead  to  obesity  (Table  2).  Clinical  features 
would  suggest  the  presence  of  one  of  these  syn- 
dromes and  standard  diagnostic  testing  would 
document  it.  DNA  testing  is  also  available  for  some 
of  them.  A Mendelian  family  history  would  usu- 
ally be  found. 

The  classical  recognizable  obesity  syndromes 
are  outlined  in  Table  3.  One  of  the  strongest  indi- 
cations of  the  presence  of  one  of  these  syndromes 
is  mental  defect,  which  occurs  in  all  but  two  of 
them.  A very  careful  diagnostic  evaluation  for  these 
syndromes  is  indicated  for  any  obese  patient  with 


J La  State  Med  Soc  VOL  1 52  January  2000  25 


Table  3 

Classical  Recognizable  Obesity  Syndromes 

OMIM 

Locus  Syndrome,  inheritance 

Recognizable  features 

203800 

2p1 4 Alstrom  syndrome*,  Autosomal  recessive 

Retinitis  pigmentosa,  progressive  deafness, 
nephropathy,  diabetes 

209901 

1 1 ql  3,  Bardet-Biedl  syndrome*, 
16q21,  Autosomal  recessive 
15q22.3, 

2q3 

Mental  defect,  pigmentary  retinopathy, 
renal  malformation,  hypogenitalism, 
polydactyly 

210350 

? Biemond  syndrome  II,  Autosomal  recessive 

Mental  defect,  coloboma,  short  stature, 
hypogenitalism,  polydactyly, 

301900 

Xq26.3  Borjeson-Forssman-Lehmann  syndrome, 
X-linked  recessive 

Mental  defect,  epilepsy,  hypogonadism, 
hypometabolism,  swelling  of  subcutaneous 
tissue  of  face,  narrow  palpebral  fissure, 
large  ears 

309490 

? Chudley  syndrome,  X-linked  recessive 

Mental  defect,  short  stature,  hypogonadism, 
bitemporal  narrowness,  depressed  nasal 
bridge,  short  and  inverted-V-shaped  upper 
lip,  macrostomia 

216550 

8q22  Cohen  syndrome,  Autosomal  recessive 

Mental  defect,  high  nasal  bridge,  strabismus, 
large  ears,  prominent  incisors,  narrow  hand, 
tapering  fingers 

601794 

? Coloboma-obesity-hypogenitalism-mental 

retardation,  Autosomal  dominant 

Mental  defect,  microphthalmia,  coloboma, 
cataract,  hypogenitalism 

300148 

Xp22.13  MEHMO  syndrome,  X-linked  recessive 

Mental  defect,  epilepsy,  hypogonadism  and 
hypogenitalism,  microcephaly 

157980 

? MOMO  syndrome,  Autosomal  dominant 

Mental  defect,  macrocephaly,  coloboma, 
nystagmus,  down  eye  slant,  delayed  bone 
maturation 

176270 

1 5q1 1 Prader-Willi  syndrome*,  Autosomal  dominant 

Mental  defect,  neonatal  hypotonia, 
bitemporal  narrowness,  small  hands  & feet, 
hypogonadism,  short  stature,  diabetes 

181450 

1 2q24.1  Ulnar-mammary  syndrome*,  Autosomal  dominant 

Breast  hypoplasia,  axillary  apocrine  gland 
hypoplasia,  ulnar  hypoplasia,  malformation  or 
absence  of  fingers  4 and  5 including  metacar- 
pals,  small  penis,  delayed  puberty, 
anal  atresia,  pyloric  stenosis,  congenital 
subglottic  cartilaginous  web 

309585 

Xp21 .1  Vasquez  syndrome,  X-linked  recessive 

Mental  defect,  gynecomastia,  hypogonadism, 
short  stature,  tapering  fingers,  small  feet 

*DNA  test  available 

26  J La  State  Med  Soc  VOL  152  January  2000 


a mental  defect.  The  syndromes  often  entail  a spec- 
trum of  abnormalities  about  which  it  is  important 
to  know  for  management  and  prognosis.  Most  of 
them  also  entail  a considerable  genetic  risk  to  prog- 
eny of  the  patient  or  relatives.  Pathogenesis  of  the 
obesity  in  these  syndromes  is  indefinite  but  com- 
pulsive eating  seems  to  be  a final  common  path- 
way. Some  work  in  the  Prader-Willi  syndrome  has 
shown  decreased  energy  utilization  and  decreased 
lipolysis.  Weight  reduction  may  be  safely  accom- 
plished through  metered  intake  in  most  cases. 

GENETIC  COUNSELING 

Ponderosity  has  long  been  known  to  be  famil- 
ial but  studies  of  actual  inheritance  of  obesity  have 
been  confounded  by  non-genetic  familial  and  cul- 
tural factors.  Cases  that  are  clearly  due  to  a syn- 
drome are  rare,  but  standard  Mendelian  risk  fig- 
ures adequately  characterize  the  likelihood  of  obe- 
sity in  relatives  in  those  cases:  autosomal  domi- 
nant (50%  risk  to  progeny  of  affected  persons), 
autosomal  recessive  (25%  risk  to  sibs  of  affected 
persons),  or  X-linked  (50%  risk  to  brothers  of  af- 
fected males).  In  some  cases,  testing  for  the  pres- 
ence of  the  gene  or  the  metabolic  error  makes  risk 
estimation  more  accurate  for  individuals.  Sources 
of  tests  are  available  online  at  http:  / / 
www.genetests.org/ . 

For  the  more  common  polygenic  obesity,  the 
most  informative  data  are  from  studies  that  com- 
pare adoptees  to  their  biological  and  adoptive  par- 
ents, and  twins  reared  together  and  apart.  Actual 
risk  figures  derived  from  those  studies  indicate  a 
genetic  risk  of  about  40%  for  obesity  in  the 
monozygotic  twin  of  an  obese  person  and  about 
3%  for  obesity  in  other  first  degree  relatives  of  an 
obese  person.  The  figures  are  probably  accurate 
for  all  variants  of  polygenic  obesity.  Mendelian 
inheritance  is  associated  with  higher  figures.  A 
high  frequency  of  obesity  in  a family,  particularly 
if  it  is  limited  to  one  side  of  the  family,  indicates  a 
need  for  careful  diagnostic  investigation  for  fea- 
tures of  a Mendelian  syndrome 

Early  feeding  influence  is  a time-honored  as- 
pect of  the  maternal  effects  that  heighten  the  simi- 
larity among  sibs  above  that  expected  due  to  ge- 
netic factors.  It  could  lead  to  a concentration  of 
obesity  due  to  entrained  gluttony  among  children 
of  women  whose  obesity  is  due  to  any  number  of 
other  causes.  However,  studies  place  that  likeli- 


hood at  about  4%  or  about  the  same  as  the  fre- 
quency of  gluttony  in  general. 

There  is  decided  assortative  mating  for  quan- 
titative traits.  The  best-documented  effect  of  as- 
sortative mating  on  a quantitative  trait  is  that  of 
intelligence,  in  which  the  average  intelligence  of 
progeny  is  above  two  standard  deviations  if  both 
parents  are  above  two  standard  deviations.  Assor- 
tative mating  for  obesity  has  not  been  documented 
to  that  degree  but  it  is  quite  likely  that  progeny 
could  be  obese  on  average  if  both  parents  had  the 
same  variety  of  polygenic  obesity.  That  would  pro- 
duce a bilateral  family  history  of  obesity  that  would 
not  be  typical  of  a Mendelian  pattern. 

CODING  AND  TREATMENT 

ICD9-CM  codes  that  include  "obesity"  in  ter- 
minology are  inaccurate  and  misleading.  Payment 
plans  may  disallow  services  based  on  those  codes. 
Obesity  is  an  end  result.  To  code  for  obesity  per  se 
is  no  more  meaningful  than  to  code  for  the  depig- 
mentation that  is  an  end  result  of  phenylketonuria. 
To  include  "obesity"  in  the  description  of  the  prob- 
lem is  no  more  necessary  than  it  is  to  include  "de- 
pigmentation" in  the  description  of  phenylketo- 
nuria. Current  codes  in  the  ICD9-CM  are  not  opti- 
mal for  polygenic  diseases  so  the  closest  similar 
code  should  be  used.  Accurate  terms  and  codes 
for  patients  with  polygenic  obesity  are  as  follows: 
Predominant  neurotransmitter  inadequacy,  270.2; 
Predominant  acylation  inadequacy,  272.9;  Pre- 
dominant thermogenesis  inadequacy,  271.9;  Com- 
bined metabolic  inadequacies,  277.9.  The  most 
optimal  code  for  gluttony  is  307.5.  There  are  spe- 
cific codes  for  many  of  the  Mendelian  disorders 
and  syndromes.  Close  attention  to  the  actual  de- 
fect allows  for  accurate  coding  of  the  others. 

The  key  to  treatment  of  obesity  is  the  realiza- 
tion that  it  results  from  constitutional  variations 
that  are  lifelong  and  cannot  be  cured.  Management 
and  control  require  either  continual  or  episodic 
treatment.  Treatment  is  difficult  in  all  cases  and 
dangerous  in  some,  but  the  margin  of  success  can 
be  improved  by  tailoring  the  treatment  to  the  un- 
derlying cause.  One  process  may  be  the  pre- 
dominant one.  In  most  studies,  obese  patients  sig- 
nificantly underreport  intake;  however,  if  normal 
intake  can  be  unequivocally  established,  thermo- 
genesis is  likely  to  be  the  major  process  at  fault. 
Other  polygenic  processes  may  be  more  difficult 


J La  State  Med  Soc  VOL  152  January  2000  27 


to  recognize,  but  careful  interview,  including  ob- 
servations of  relatives  and  acquaintances,  may 
elicit  recognizable  features.  Recognizable  features 
may  also  arise  during  therapeutic  trials. 

A Mendelian  distribution  of  obesity  in  the 
family  is  an  indication  of  the  presence  of  one  of 
the  major  genes  for  obesity.  Currently,  there  is  no 
other  practical  diagnostic  approach.  Treatment  for 
Mendelian  obesity  is  the  same  as  for  polygenic 
obesity  except  for  added  caution  in  regard  to  pos- 
sible metabolic  decompensation.  Syndromes  with 
features  that  lead  to  obesity  may  have  to  be  treated 
in  the  same  manner;  however,  treatment  of  the 
syndrome  itself  may  resolve  the  obesity.  For  ex- 
ample, hormonal  therapy  of  the  polycystic  ovary 
syndrome  counters  insulin  resistance  and  reduces 
abdominal  fat  deposition. 

One  of  the  problems  in  obesity  treatment  is 
defining  an  endpoint.  If  there  is  a clear  time  of  onset 
of  obesity,  photographs,  weight  records,  and 
clothes  sizes  allow  an  endpoint  to  be  defined  as  a 
return  to  the  pre-obese  state.  Decrements  of  body 
mass  index  toward  the  50th  percentile  represent 
significant  progress  in  control  of  obesity.  If  that 
process  plateaus  at  a point  where  diet,  eating  be- 
havior, and  life  style  seem  optimal,  one  has  reached 
a working  endpoint.  Patients  who  become  over- 
zealous  about  obesity  treatment  and  who  were 
formerly  below  the  50th  percentile  for  body  mass 
index,  may  drop  past  the  50th  percentile  during 
treatment.  If  the  body  mass  index  in  those  patients 
drops  to  the  10th  percentile,  the  physician  should 
call  a halt  to  the  process  and  try  to  stabilize  weight 
at  that  point.  Psychiatry  consultation  is  indicated 
if  weight  drops  lower  and  the  process  seems  to  be 
out  of  control. 

The  multiple  processes  that  lead  to  obesity 
make  it  unlikely  that  currently  available  drug  treat- 
ment will  benefit  the  majority  of  cases.  It  is  most 
applicable  in  patients  with  inadequate  neurotrans- 
mitter mechanism.  Some  types  of  depressive  dis- 
orders share  the  same  biochemical  problem  as  the 
neurotransmitter  defect  and  may  co-exist  with 
obesity,  requiring  more  specific  management. 
Anti-obesity  drugs  may  have  unfortunate  effects 
on  patients  with  other  psychiatric  disorders  or  may 
have  untoward  interactions  with  drugs  used  to 
treat  them. 

Serotonin  agonists  and  serotonin  uptake  in- 
hibitors are  the  most  popular  anti-obesity  drugs. 


Most  of  them  effectively  staunch  eating  in  patients 
with  neurotransmitter  inadequacy  but  are  subject 
to  addiction  and  tachyphylaxis  as  well  as  untoward 
side  effects.  Online  services  like  http:// 
www.mdconsult.com/  can  provide  current  au- 
thoritative information.  Search  it  for  " obesity  treat- 
ment benefits".  None  of  the  drugs  has  a long-term 
advantage  over  diet  and  exercise.  Alternative 
therapies  like  phototherapy  or  5-hydroxytry- 
ptophan  may  be  equally  effective  but  require  close 
observation  for  currently  unknown  side  effects. 

Phototherapy  involves  sitting  under  a bank 
of  fluorescent  lights  providing  at  least  1500  lux  to 
face  and  shoulders  from  6 a.m.-8  a.m.  each  morn- 
ing, initially  for  10  days,  then  on  Monday  and 
Thursday  as  maintenance.  The  dose  of  5- 
hydroxytryptophan  is  300  mg  3 times  daily,  30 
minutes  before  main  meals.  If  there  is  a place  for 
this  drug,  it  is  in  young  adult  obese  patients  with 
no  co-morbidity.  It  may  be  hazardous  in 
hypertensives,  in  patients  with  sympatho amine- 
secreting  tumors,  and  in  other  disease  states.  Drug 
interactions  have  not  been  investigated. 

Currently  approved  drugs  have  little  efficacy 
in  problems  of  acylation,  thermogenesis,  or  glut- 
tony other  than  an  evanescent  non-specific  anorec- 
tic effect.  Cachectin  (tumor  necrosis  factor  alpha) 
is  under  study  as  a more  general  anti-obesity  drug. 
It  causes  weight  loss  due  to  anorexia  in  experimen- 
tal models;  however,  its  very  nature  makes  dan- 
gerous side  effects  likely.  The  current  therapeutic 
approach  to  obesity  due  to  problems  other  than 
neurotransmission  is  the  combination  of  diet,  ex- 
ercise, behavior  therapy,  and  life-style  counseling. 
These  are  the  only  approved  approaches  to  any 
type  of  obesity  in  children  and  pregnant  women. 
Actual  weight  loss  during  pregnancy  may  be  haz- 
ardous to  the  fetus. 

Diet,  exercise,  behavior  therapy,  and  life-style 
counseling  should  also  be  given  concurrently  with 
drug  therapy  or  alternative  therapies.  Behavior 
therapy  and  life-style  counseling  are  based  on  as- 
sumptions that  the  patient  does  not  know  about 
the  importance  of  eating  behaviors  and  life  style 
in  weight  control,  does  not  appreciate  their  sig- 
nificance, or  is  distracted.  There  are  well-docu- 
mented assessment  instruments  that  therapists  can 
use  to  identify  behavior  and  life-style  problems 
and  recommend  resolutions.  The  patient  is  encour- 
aged toward  a frugal  diet  and  an  active  life  style. 


28  J La  State  Med  Soc  VOL  1 52  January  2000 


Periodic  reviews  and  reinforcement  techniques  are 
used.  Excellent  benefit  has  been  shown  from  on- 
going or  episodic  rounds  of  behavior  therapy  and 
life  style  counseling.  Older  physicians  may  think 
of  this  as  "brain-washing".  It  is  outlined  on  http:  / 
/ www.mdconsult.com/ . Due  to  the  time  commit- 
ment, many  physicians  will  find  it  best  to  refer  the 
patient  to  a counseling  service  for  these  purposes. 
Professional  dietitians  may  offer  counseling  and 
follow-through.  Many  hospitals  now  provide  ex- 
ercise and  counseling  programs. 

Some  self-selection  is  necessary  because  the 
patient  must  provide  the  impetus  for  follow- 
through  of  treatment.  Due  to  the  chronicity  of  the 
problem,  even  the  most  highly  motivated  patients 
require  encouragement,  monitoring  and  recall  by 
the  physician.  Excellent  weight  reduction  diet 
plans  are  widely  available,  eg,  http:  / / 
www.mdconsult.com/.  The  error  of  undue  con- 
centration on  any  one  modality  should  be  empha- 
sized. Dieting  is  seldom  efficacious  without  behav- 
ioral therapy  and  life-style  counseling.  Exercise 
alone  can  be  particularly  disappointing,  as  the  pro- 
digious amounts  required  to  burn  only  a few  calo- 
ries can  lead  to  exhaustion.  Emphasis  should  be 
on  the  place  of  an  exercise  program  in  an  active 
life  style  and  cardiovascular  health  rather  than  on 
any  direct  relationship  between  exercise  and 
weight  loss. 

The  mental  defect  that  is  typical  of  many  clas- 
sical recognizable  obesity  syndromes  requires  en- 
listment of  the  caretaker  in  treatment.  Management 
programs  in  these  cases  may  already  have  opti- 
mized aspects  other  than  diet;  however,  it  is  im- 
portant to  review  meal  and  exercise  practices.  It 
often  will  be  found  that  the  most  advantageous 
changes  are  to  arrange  meals  with  correct  calorie 
and  nutrition  content  and  to  curtail  access  to  any 
other  foods. 

The  caretaker  or  caretakers  must  also  be  en- 
listed in  the  treatment  of  obesity  of  childhood,  the 
difference  being  that  there  may  be  no  pre-existing 
program  to  manage  exercise  and  counseling.  While 
caretakers  may  pose  a significant  barrier  to  man- 
agement of  childhood  obesity,  the  continual 
growth  is  a significant  advantage.  Minor  successes 
in  diet,  exercise,  behavior,  and  life  style  can  lead 
to  appreciable  improvement.  Because  of  the  life- 
long nature  of  obesity,  it  is  quite  important  to  in- 
clude the  child  in  all  aspects  of  counseling,  with 


age-appropriate  vocabulary.  Plans  should  always 
be  made  for  transition  to  adult  management. 

For  patients  who  have  the  means,  reputable 
retreats  and  spas  have  a real  place  in  obesity  man- 
agement as  a respite  and  an  opportunity  to  refresh 
the  management  regimen.  However,  some  retreats 
and  spas  are  useless  or  harmful.  Before  endorsing 
any  adjunct  like  that,  the  physician  should  care- 
fully investigate  and  document  the  program.  Like 
any  other  form  of  obesity  management,  these  are 
without  long-lasting  effects  and  resort  to  them  may 
be  required  recurrently,  so  they  are  of  little  value 
to  patients  of  limited  means. 

Even  a seemingly  harmless  weight  reduction 
diet  could  have  untoward  results.  Most  are  clearly 
inadequate  for  patients  undertaking  moderate  to 
severe  exertion  and  for  patients  with  intercurrent 
medical  illnesses.  Patients  whose  obesity  is  a com- 
pensation for  a rare  Mendelian  inborn  error  may 
revert  to  an  uncompensated  state,  so  contact  with 
each  patient  must  be  maintained  while  on  the  diet 
and  the  diet  should  be  discontinued  if  there  are 
signs  of  decompensation.  A weekly  checkup  is 
prudent.  The  marginal  nutritional  content  of  most 
weight  reduction  diets  will  lead  to  weight  loss 
within  2 weeks.  They  are  highly  effective  for  glut- 
tony and  serve  as  a demonstration  of  the  source  of 
the  problem  to  the  patient. 

Weight  gain  on  a standard  weight  reduction 
diet  is  usually  a sign  of  cheating,  which  is  likely  in 
cases  of  neurotransmitter  or  acylation  inadequacy. 
A more  closely  controlled  diet  such  as  the  protein- 
sparing modified  fast  may  be  required  for  patients 
with  those  problems.12  That  severe  approach,  if 
successful,  may  test  the  limits  of  therapeusis. 
Weight  loss  may  occur  at  the  expense  of  health  in 
some  cases.  Patients  with  predominant  neurotrans- 
mitter defect  may  experience  sleep  disorders  and 
chronic  fatigue.  Patients  with  predominant  acyla- 
tion defect  may  develop  malaise.  Some  degree  of 
obesity  may  be  required  to  prevent  them  from  laps- 
ing into  malnutrition.  After  the  diet  period,  pa- 
tients with  neurotransmitter  inadequacy  will  still 
be  driven  to  eat  and  may  benefit  from  recycling 
through  drug  therapy. 

Patients  with  inadequate  thermogenesis  usu- 
ally do  not  require  severe  diets.  Standard  weight 
reduction  diets  are  effective  but  these  patients  may 
have  a "knife-edge"  nutritional  balance  that  re- 
quires careful  tuning  of  intake.  Intake  below  nor- 


J La  State  Med  Soc  VOL  1 52  January  2000  29 


mal  is  required  for  weight  maintenance  but  not  so 
far  below  normal  that  it  compromises  health.  A 
BMR  is  a practical,  objective  assessment.  A steady 
decline  which  passes  -15%  indicates  that  maximum 
dietary  benefit  has  been  achieved,  and  additional 
nutrients  should  be  added.  A practical  approach 
is  to  cycle  the  patient  between  a normal  diet  and  a 
weight-reduction  diet. 

In  any  form  of  obesity,  weight  loss  should  be 
considered  a remission.  There  will  be  a relapse  af- 
ter variable  periods  of  time  in  almost  all  cases,  usu- 
ally after  behavioral  and  life-style  adjustments  fal- 
ter. Periodic  evaluations  will  allow  the  treating 
physician  to  gauge  this  process  and  decide  when 
to  re-institute  treatment. 

REFERENCES 

1 . Thurmon  TF.  A Comprehensive  Primer  on  Medical  Genetics. 
New  York;  Parthenon  Publishing;  1999:321-322. 

2.  Simopoulos  AP.  Characteristics  of  obesity:  an  overview. 
Ann  NY  Acad  Sci  1987;499:4-13. 

3.  Wurtman  RJ,  Wurtman  JJ.  Carbohydrates  and  depression. 

Scientific  Am  1989;Jan:68-75. 

4.  Jeanrenaud  B,  Cusin  I,  Rohner-Jeanrenaud  F.  From  Claude 

Bernard  to  the  regulatory  system  between  the 
hypothalamus  and  the  periphery:  implications  for 
homeostasis  of  body  weight  and  obesity.  C R Seances 
Biol  Fil  1998;192:829-841. 


5.  Leibel  RL,  Hirsch  J,  Berry  EM,  et  al.  Alterations  in 

adipocyte  free  fatty  acid  re-esterification  associated  with 
obesity  and  weight  reduction  in  man.  Am  J Clin  Nutr 
1985;42:198-206. 

6.  Guo  Z,  Hensrud  DD,  Johnson  CM,  et  al.  Regional 
postprandial  fatty  acid  metabolism  in  different  obesity 
phenotypes.  Diabetes  1999;48:586-592. 

7.  Jequier  E.  Energy  expenditure  in  obesity.  Clin  Endocrinol 

Metab  1984;13:563-580. 

8.  Schrauwen  P,  Walder  K,  Ravussin  E.  Fluman  uncoupling 

proteins  and  obesity.  Obes  Res  1999;7:97-105. 

9.  Echwald  SM.  Genetics  of  human  obesity:  lessons  from 
mouse  models  and  candidate  genes.  / Intern  Med 
1999;245:653-666. 

10.  McKusick  VA.  Mendelian  Inheritance  in  Man:  A Catalogue 
of  Human  Genes  and  Genetic  Disorders.  Baltimore:  Johns 
Hopkins  Press;  1998. 

11.  Online  Mendelian  Inheritance  in  Man,  OMIM.  Center  for 
Medical  Genetics,  Johns  Hopkins  University  (Baltimore, 
Md)  and  National  Center  for  Biotechnology  Information, 
National  Library  of  Medicine  (Bethesda,  Md),  1998. 
World  Wide  Web  URL:  http:  / / www.ncbi.nlm.nih.gov/ 
omim/ 

12.  Seim  HC,  Rigden  SR.  Approaching  the  protein-sparing 

modified  fast.  Am  Earn  Physician  1990;42(suppl  5):51S- 
56S. 


Dr  Thurmon  is  a professor  of  Pediatrics  in  the  Louisiana  State  University 
School  of  Medicine  in  Shreveport,  Louisiana. 


30  J La  State  Med  Soc  VOL  1 52  January  2000 


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DANDY-WALKER  SYNDROME: 


PRESENTATION  OF  THE  CONGENITAL  MALFORMATION  IN  AN  OLDER  PATIENT 


Praveen  Reddy,  MD;  Prasad  S.S.V.  Vannemreddy,  MD; 
Laurie  Grier,  MD;  Anil  Nanda,  MD 


Dandy- Walker  syndrome,  a congenital  malformation  of  the  hindbrain  involving  the  cerebellum  and  the 
fourth  ventricle,  is  a rare  cranial  abnormality  that  commonly  occurs  before  the  sixth  or  seventh  week  of 
development.  It  is  usually  diagnosed  at  birth  or  in  early  childhood;  however,  an  occasional  patient  may 
first  become  symptomatic  in  adult  life.  A case  of  Dandy-Walker  syndrome  in  a 58-year-old  woman  is 
reported  because  of  the  older  age  at  presentation  and  relatively  long  asymptomatic  period  after  birth. 


The  term  Dandy- Walker  syndrome  (DWS) 
was  coined  by  Benda  in  1954.1  It  is  a con- 
genital anomaly  of  the  central  nervous  sys- 
tem characterized  by  the  triad  of  (a)  a posterior 
fossa  cyst  due  to  abnormal  dilatation  of  the  fourth 
ventricle,  (b)  agenesis  or  hypoplasia  of  the  cerebel- 
lar vermis,  and  (c)  hydrocephalus  due  to  atresia 
or  absence  of  the  foramina  of  Luschka  and 
Magendie.2 

It  may  be  commonly  associated  with  other 
neural  (gyral  anomalies  ranging  from  agyria  to 
polymicrogyria,  agenesis  of  corpus  collosum,  in- 
fundibular hamartomas,  posterior  fossa  lympho- 
mas and  lipomas,  aqueductal  stenosis,  syringomy- 
elia cerebellar  hypoplasia,  and  occipital 
meningoceles)  and  non-neural  (cleft  palate,  poly- 


cystic kidneys,  polydactyly,  syndactyly,  vertebral 
anomalies,  cataracts,  and  retinal  dysgenesis)  ab- 
normalities.3 

DWS  usually  manifests  at  birth  or  in  early  in- 
fancy with  hydrocephalus,  slow  motor  develop- 
ment, and  mental  retardation  or  seizures.  In  older 
children,  symptoms  of  increased  intracranial  pres- 
sure such  as  irritability,  vomiting  and  convulsions, 
or  signs  of  cerebellar  dysfunction  such  as  ataxia 
and  nystagmus  may  occur.  It  is  unusual  for  DWS 
to  be  asymptomatic  throughout  infancy  and  child- 
hood and  manifest  late  in  adulthood.  The  oldest 
patient  reported  was  72  years  of  age4  with  symp- 
toms of  raised  intracranial  pressure  and  cerebel- 
lar and  brainstem  dysfunction.  Pre-natal 
sonography  can  be  used  to  detect  DWS  in  utero  or 


J La  State  Med  Soc  VOL  152  January  2000  31 


a diagnosis  can  be  made  antenatally  by  plain  roent- 
genogram, ultrasound,  cerebral  angiography,  CT, 
or  MRI. 5 A case  of  Dandy-Walker  cyst  presenting 
in  an  older  patient  is  reported. 

CASE  REPORT 

A 58-year-old,  African-American  woman  was 
transferred  from  a local  nursing  home  with  com- 
plaints of  altered  mental  status  of  6-8  hours  dura- 
tion. Closer  questioning  of  nursing  home  person- 
nel and  relatives  revealed  a past  medical  history 
significant  for  hypertension,  diabetes,  and  a left 
cerebrovascular  accident  in  1995.  Unfortunately, 
no  clinical  or  radiological  reports  of  those  hospi- 
talizations were  available.  Two  years  previously, 
the  patient  was  placed  in  a nursing  home  because 
of  residual  weakness  on  her  right  side.  The  patient 
was  able  to  perform  routine  daily  activities  by  her- 
self and  never  complained  of  headaches,  visual 
difficulties,  or  persistent  nausea  and  vomiting. 

At  the  time  of  admission,  the  patient  was  le- 
thargic, not  oriented,  and  not  responding  to  ver- 
bal commands.  Pupils  were  3 mm  on  both  sides, 
round,  and  reactive  to  light.  The  patient  was 
hyporeflexic  on  the  right  side  and  Babinski's  was 
equivocal.  Her  laboratory  workup  was  within  nor- 
mal limits.  A CT  scan  was  done  (Figure),  which 


Figure.  Axial  CT  (non-contrast)  demonstrates  the  posterior 
fossa  cyst,  communicating  with  the  fourth  ventricle.  There  is 
panventricular  dilatation. 


revealed  hydrocephalus,  and  a large  posterior 
fossa  cyst  communicating  with  the  enlarged  fourth 
ventricle.  She  required  endotracheal  intubation,  as 
the  sensorium  gradually  deteriorated.  After  dis- 
cussing the  neurological  condition  of  the  patient, 
the  family  decided  not  to  undergo  any  surgical 
intervention  and  consented  to  a DNR  (do  not  re- 
suscitate) status.  No  further  MRI,  EEG,  or  cerebral 
angiogram  could  be  obtained  subsequently.  After 
5 days  of  ventilatory  support,  the  patient  was  ex- 
tubated  and  she  expired.  Family  members  refused 
an  autopsy  study. 

DISCUSSION 

Dandy- Walker  malformations,  though  the 
exact  etiology  is  not  known,  are  believed  to  result 
from  insults  to  the  developing  nervous  system  by 
genetic  or  environmental  factors.  An  increased  in- 
cidence of  DWS  was  associated  with  warfarin  or 
isotretinoin6  use  during  pregnancy.  Although  DWS 
is  almost  always  a pediatric  anomaly,  cases  of 
adults  with  DWS  have  been  reported  in  the  litera- 
ture in  recent  years.  These  may  be  asymptomatic 
or  symptomatic  with  manifestations  of  raised  in- 
tracranial pressure  and  cerebellar  or  brain  stem 
dysfunction.  In  the  present  case,  the  patient  was 
asymptomatic  until  53  years  of  age,  when  she  suf- 
fered a CVA,  which  may  or  may  not  have  been 
related  to  DWS.  The  cause  for  altered  mental  sta- 
tus change  at  the  time  of  this  event  could  have  been 
due  to  raised  intracranial  pressure  secondary  to 
DWS. 

Unsgaard  et  al  reviewed  the  cases  reported  in 
the  literature.7  Only  three  cases  were  reported  in 
the  literature  between  1987  and  1996.  The  Table 
shows  some  features  of  the  patients  with  DWS 
presenting  in  adolescent  and  adult  life.  The  mean 
age  of  these  20  patients  is  34  years.  Fifty  percent  of 
these  cases  were  older  than  31  years  at  presenta- 
tion. Increased  intracranial  pressure  and  gait  ataxia 
were  the  most  common  clinical  findings,  account- 
ing for  62%  and  38%,  respectively. 

The  explanation  for  delayed  presentation  in 
certain  cases  is  unclear.  In  these  cases,  the  small 
openings  present  in  the  cyst  membrane  are  effec- 
tive or  the  foramina  of  Lushka  may  be  patent.  In 
some  cases,  contrast  cisternography  or  ventricu- 
lography2' 7 can  demonstrate  this  communication 
between  the  cyst  and  the  subarachnoid  space. 
These  communications  between  the  Dandy- 


32  J la  State  Med  Soc  VOL  1 52  January  2000 


Table 

Patients  Presentins  with  Dandy-Walker  Syndrome  Later  in  Life 

S No. 

AUTHOR 

AGE 

SEX 

PRESENTING  COMPLAINT 

1. 

Sato  et  al  1 996 

35 

F 

headache,  gait  disturb 

2. 

Herbert  et  al  1995 

53 

F 

headache,  gait  disturb 

3. 

Herbert  et  al  1995 

50 

F 

visual  loss,  diplopia, 

4. 

Unsgaard  et  al  1987 

69 

F 

gait  disturbance 

5. 

Unsgaard  et  al  1987 

44 

M 

brain  stem  dysfunction 

6. 

Cox  et  al  1979 

27 

rebound  nystagmus 

7. 

Upton  et  al  1979 

34 

raised  ICP,  diplopia 

8. 

Epstein  et  al  1975 

14 

raised  ICP 

9. 

Epstein  et  al  1975 

34 

raised  ICP 

10. 

Gardner  et  al  1975 

72 

ataxia 

11. 

Engelhardt  et  al  1975 

40 

ICP 

12. 

Hubert  et  al  1974 

26 

ICP,  ataxia 

13. 

Agostino  et  al  1 963 

23 

hemiparisis 

14. 

Whitten  et  al  1976 

21 

ICP,  subdural  hematoma 

15. 

Maloney  et  al  1954 

13 

ICP,  palsy 

16. 

Coleman  et  al  1948 

17 

ICP,  ataxia 

17. 

Walker  1 944 

20 

ICP 

18. 

Cohen  1942 

13 

ICP,  ataxia,  diplopia 

19. 

Sahs  1941 

16 

ICP,  ataxia 

20. 

Castrillon  1933 

59 

ICP 

Walker  cyst  and  other  CSF  compartments  may  ef- 
fectively mitigate  pressure  effects  of  the  accumu- 
lating fluid  until  late  in  life.  However,  in  the  ma- 
jority, this  communication  is  valvular. 

Diagnosis  of  DWS  is  established  promptly  by 
present  day  neuro-imaging.  Plain  x-ray  films  of  the 
skull  show  a high  inion  and  a deep  posterior  fossa 
with  superior  displacement  of  the  torcular 
herophili.  Cerebral  angiography  reveals  an  avas- 
cular area  corresponding  to  the  posteriorly-located 
cyst  and  hypoplastic  posterior  inferior  cerebellar 
arteries.  Contrast  cisternography  and  ventriculo- 
graphy are  useful  in  demonstrating  the  communi- 
cations of  the  cyst.  Currently,  CT  and  MRI  are  the 
diagnostic  modalities  of  choice,  and  they  show  a 
grossly  deformed  fourth  ventricle  occupying  most 
of  the  posterior  fossa  along  with  other  associated 
neurological  anomalies. 

With  the  advent  of  newer  radiological  tech- 
niques and  treatment  modalities,  the  mortality 
from  DWS,  especially  in  children,  has  decreased 
considerably  from  100%  in  1942  to  less  than  10% 
in  recent  years.8 

Fluid-diversion  procedures  and  cyst  excision 


have  both  been  reported  to  be  effective.  It  is  inter- 
esting to  note  the  effective  absorption  of  the  fluid 
that  follows  marsupialization  of  the  cyst.  This  in- 
directly demonstrates  that  CSF  absorptive  path- 
ways and  mechanisms  remain  intact  in  a DW 
anomaly.  With  effective  absorption  and  periodic 
efflux  of  cyst  fluid  through  the  pores  in  the  mem- 
brane, it  is  theoretically  possible  to  have  a latent 
DW  cyst  until  late  in  life.  The  term  asymptomatic 
may  not  be  true  in  these  cases,  since  some  form  of 
neurological  presentation  might  have  possibly 
gone  unrecorded,  as  is  the  case  in  our  patient.  In 
some  instances,  DW  cyst  was  diagnosed  by  CT 
incidentally  or  after  minor  head  trauma.9'12  In  a few 
of  these  cases,  the  symptoms  were  subtle,  prob- 
ably because  of  effective  drainage  of  the  cyst  which 
kept  the  pressure  below  the  critical  level. 


REFERENCES 

1.  Benda  CE.  The  Dandv-Walker  Syndrome  or  the  so  called 
atresia  of  the  foramen  Magendie.  J Neurcrpathol  Exp  Neurol 
1954;13:14-29. 

2.  Sato  K,  Kubota  T,  Nakamura  Y.  Adult  onset  of  the 
Dandy- Walker  syndrome.  Br  J Neurosurg  1996;10:109-112. 

3.  Hubbert  CH,  Faris  AA,  Martinez  AJ.  Dandy-Walker 


J La  State  Med  Soc  VOL  152  January  2000  33 


syndrome:  spectrum  of  congenital  anomalies.  South  Med 
J 1974;67:274-277. 

4.  Gardner  E,  O'Rahilly  R,  Prolo  D.  The  Dandy- Walker  and 
Arnold-Chiari  malformations:  clinical,  developmental 
and  teratological  considerations.  Arch  Neurol 
1975;32:393-407. 

5.  Cornford  E,  Twining  P.  The  Dandy-Walker  syndrome: 
the  value  of  antenatal  diagnosis.  Clin  Radiol  1992;45:172- 
174. 

6.  Kaplan  LC,  Anderson  GG,  Ring  BA.  Congenital 
hydrocephalus  and  Dandy-Walker  malformations 
associated  with  warfarin  use  during  pregnancy.  Birth 
Defects:  Original  Article  Series  1982;18:79-83. 

7.  Unsgaard  G,  Sand  T,  Stovring  J,  et  al.  Adult 
manifestation  of  the  Dandy-Walker  syndrome.  Report 
of  two  cases  with  review  of  the  literature.  Neuro-Chirurgie 
1987;30:21-24. 

8.  Asai  A,  Hoffman  HJ,  Hendrick  EB,  et  al.  Dandy- Walker 
syndrome:  experience  at  the  Hospital  for  Sick  Children, 
Toronto.  Pediatr  Neurosurg  1989;15:66-73. 

9.  Dandy  WE.  The  diagnosis  and  treatment  of 
hydrocephalus  due  to  occlusions  of  the  foramina  of 
Magendie  and  Luschka.  Surg  Gynecol  Obstet  1921;32:112- 
124. 

10.  Lipton  HL,  Preziosi  TJ,  Moses  H.  Adult  onset  of  the 


Dandy-Walker  syndrome.  Arch  Neurol  1978;35:672-674. 

11.  Masdeu  JC,  Dobben  GD,  Azar-Kia  B.  Dandy- Walker 
syndrome  studied  by  computed  tomography  and 
pneumoencephalography.  Radiology  1983;147:109-114. 

12.  Stovall  JM,  Venkatesh  R.  Magnetic  resonance  imaging 
of  an  adult  with  the  Dandy-Walker  syndrome.  J Natl  Med 
Ass  1988;80:1241-3, 1246-1247. 


Dr  Reddy  is  a resident  in  the  Department  of  Internal  Medicine  at 
Louisiana  State  University  Health  Services  Center 
in  Shreveport,  Louisiana. 

Dr  Vannemreddy  is  Research  Fellow  in  the  Department  of 
Neurosurgery  at  Louisiana  State  University  Health  Services  Center 

in  Shreveport,  Louisiana. 

Dr  Grier  is  Assistant  Professor  in  the  Department  of  Internal 
Medicine  at  Louisiana  State  University  Health  Services  Center 

in  Shreveport,  Louisiana, 

Dr  Nanda  is  Associate  Professor  and  Chairman  of  the 
Department  of  Neurosurgery  at  Louisiana  State  Health  Services  Center 

in  Shreveport,  Louisiana. 


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Traumatic  Brain  Injury 


• Stroke 

• Dementia 

• Cerebral  Palsy 

• Seizure  Disorder 


Raga  Malaty,  M.D.,  Ph.D. 

Medical  Director,  lieurobehavioral  Centre 
Assistant  Professor,  L5U  Dept,  of  Psychiatry 


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call  us  at 
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Psychiatric  Hospital 

Tenet  Louisiana  HealthSystem 

in  affiliation  with 
Louisiana  State  University 
Medical  Center 

104  Medical  Center  Drive 
Slidell,  Louisiana  70461 


34  J La  State  Med  Soc  VOL  152  January  2000 


LAFAYETTE’S  FAMILY  PRACTICE 
RESIDENCY  PROGRAM: 

PRACTICE  PATTERNS  OF  GRADUATES 

Kim  Edward  LeBlanc,  MD,  PhD;  Glenn  N.  Jones,  PhD 


The  Lafayette  Family  Practice  Residency  Pro- 
gram has  graduated  51  physicians  since 
1989.  This  review  of  the  residency  program 
was  undertaken  as  a follow-up  to  our  previous 
survey  which  was  done  5 years  ago.  The  initial 
survey  was  performed  to  support  our  assumption 
that  graduates  establish  practices  in  communities 
near  their  residency  programs. 

In  addition,  this  survey  attempted  to  deter- 
mine graduate  satisfaction  and  practice  character- 
istics. The  vast  majority  (92%)  of  the  respondents 
are  practicing  in  Louisiana  at  the  time  of  this  sur- 
vey. Sixty  percent  (60%)  are  practicing  in  commu- 
nities with  populations  of  25,  000  or  less.  This  rep- 
resents a substantial  improvement  from  the  1994 
survey.  In  addition,  the  results  suggest  that  these 
physicians  are  satisfied  in  their  careers  as  family 


physicians  which  concurs  with  the  previous  sur- 
vey. 

The  main  purpose  of  this  investigation  was  to 
determine  if  our  residency  is  continuing  to  meet 
its  primary  goal,  ie,  to  train  family  physicians  pre- 
pared to  treat  families  in  communities  of  all  sizes 
(with  particular  emphasis  for  the  smaller,  more 
needy  communities).  In  addition,  we  could  learn 
if  we  are  also  continuing  to  train  family  physicians 
who  would  stay  and  practice  in  south  central  and 
southwestern  Louisiana  in  the  region  known  as 
Acadiana.  Lastly,  we  could  determine  the  satisfac- 
tion of  our  graduates  in  their  chosen  field. 

This  most  recent  data  collection,  when  com- 
pared to  our  previous  survey  which  was  per- 
formed in  1994,  would  serve  as  an  indicator  of  the 
adequacy  of  the  residency  experience.1  It  was 


J La  State  Med  Soc  VOL  152  January  2000  3^ 


hoped  that  our  residency  has  continued  to  provide 
adequately  trained  family  physicians  for  the  sur- 
rounding communities.  Moreover,  it  is  anticipated 
that  a majority  of  these  physicians  would  practice 
in  rural  communities  in  the  Acadiana  region  of  the 
state. 

PHASE  1:  PRACTICE  LOCATION 
Methods 

A total  of  51  physicians  have  completed  the 
Lafayette  Family  Practice  Residency  Program  from 
1989  to  July  1998.  All  of  these  51  graduates  were 
mailed  the  Phase  2 survey  (described  below).  It 
requested  that  each  physician  confirm  their  ad- 
dress and  indicate  the  population  of  the  town  or 
city  where  they  practiced.  Fifty-one  percent  (51%) 
of  the  graduates  responded  to  the  survey.  Twenty- 
five  completed  the  survey,  while  two  surveys  were 
returned  as  undeliverable. 

Results 

Similar  to  our  1994  survey,  the  vast  majority 
of  the  respondents  practice  in  Louisiana  (92%), 
while  8%  practice  out  of  state.  The  1994  survey 
indicated  that  88%  practiced  in  Louisiana,  with  the 
remainder  practicing  in  southern  states.  The  gradu- 
ates of  the  Lafayette  Family  Practice  Residency 
Program  are  serving  communities  of  various  sizes. 
Sixty  percent  are  practicing  in  communities  of 
25,000  or  less.  This  is  an  improvement  over  the  1994 
survey  which  revealed  that  only  39.5%  of  the 


Table  1 

Which  Best  Describes  the  Size  of  the  Community 
Where  You  Practice? 

COMMUNITY 

POPULATION 

1994 

1999 

< 2500 

5.5% 

8.0% 

2500  - 10,000 

17% 

52% 

25,000  - 50,000 

11% 

16% 

50,000  - 100,000 

17% 

16% 

> 500,000 

17% 

16% 

City  > 500,000 

11% 

4% 

Suburban,  metropolitan 
area  of  > 500,000 

5.5% 

4% 

Does  not  equal  100%  as  not  all  respondents  responded  to 
this  question. 

graduates  were  practicing  in  communities  of  simi- 
lar population.  Ninety-two  percent  of  the  respon- 
dents are  practicing  in  communities  with  popula- 
tions of  less  than  100,000.  This,  likewise,  is  an  im- 
provement since  the  previous  survey  which  had 
67.5%  practicing  in  this  size  community.  Almost 
all  of  these  communities  are  in  the  Acadiana  re- 
gion. 

Discussion 

As  indicated  from  the  above  results,  the  pro- 
gram is  accomplishing  its  goal  of  providing  fam- 
ily physicians  for  Louisiana  communities.  Further- 
more, it  would  appear  that  this  direction  has  con- 
tinued from  1994  and  has  shown  improvement  as 
we  would  hope. 

PHASE  2:  SURVEY 

Methods 

In  early  1999,  the  graduates  were  surveyed  to 
determine  the  characteristics  of  their  practice.  This 
survey  was  very  similar  to  the  questionnaire  that 
was  administered  in  1994.  The  survey  consisted 
of  a series  of  multiple  choice  questions,  with  blanks 
for  written-in  responses  used  liberally.  Questions 
were  asked  about  practice  location,  practice  pat- 
terns, and  satisfaction  with  practice. 

Results 

Of  the  51  surveys  sent  out,  25  (51%)  were  re- 
turned. As  stated  above,  a significant  majority 
(60%)  are  practicing  in  communities  with  popula- 
tions of  25,000  or  less.  Table  1 provides  compari- 
sons from  the  previous  1994  survey  to  the  present 
1999  survey. 

The  overwhelming  majority  of  those  who  re- 
sponded are  board  certified  in  family  practice  (24/ 
25,  96%).  This  represents  an  improvement  as  pre- 
vious respondents  indicated  a 89%  certification 
rate.  Eighty-four  percent  (21/25)  indicated  that 
they  planned  to  maintain  their  certification  while 
four  did  not  respond  to  this  question.  In  1994,  89% 
indicated  that  they  would  maintain  their  certifica- 
tion. All  of  the  respondents  (100%)  indicated  that 
they  were  practicing  as  family  physicians.  This 
represented  an  increase  from  89%  reported  in  1994. 

Practice  Arrangements 

Eight  percent  characterized  their  practice  as 
fee-for-service  which  is  an  increase  from  61%  in 


36  J La  State  Med  Soc  VOL  1 52  January  2000 


the  previous  survey.  Two  (8%)  indicated  that  their 
practices  were  essentially  in  health  maintenance 
organizations  compared  to  11%  in  1994.  One  indi- 
cated employment  with  a public  community  clinic 
while  one  other  was  employed  primarily  in  an 
emergency  room  setting.  Eighty-four  percent  in- 
dicated that  they  had  a contract  with  a preferred 
provider  organization  or  an  independent  practice 
association.  This  was  a substantial  increase  from 
67%  noted  5 years  ago. 

Similar  to  the  study  survey  of  1994,  there  are 
a wide  variety  of  practice  arrangements  as  reflected 
in  the  particular  sources  of  reimbursement.  The 
breakdown  and  comparison  of  the  two  surveys  are 
listed  in  Table  2.  The  largest  group  was  represented 
by  private  insurance  which  accounted  for  33%  and 
45%  of  reimbursement  in  1994  and  1999,  respec- 
tively. Medicaid  counted  for  24%  in  1994,  yet  had 
declined  to  12%  in  the  latest  analysis.  Medicare 
reimbursement  remained  steady  at  19%  in  both 
surveys.  Prepaid  contracts,  represented  by 
capitated  at-risk  contracts  or  health  maintenance 
organizations,  declined  from  16%  in  1994  to  nearly 
10%  in  1999.  Those  making  up  the  indigent  popu- 
lation or  those  with  partial  payment  increased 
slightly  between  the  two  survey  years  from  10% 
to  12%.  Similar  to  the  previous  survey,  these  aver- 
ages fail  to  capture  the  wide  range  of  payment  ar- 
rangements. Virtually  all  of  the  physicians  re- 
ported that  their  income  came  from  three  or  more 
sources. 

A high  percentage  of  the  respondents  (84%) 
indicated  that  they  had  a contract  with  a preferred 
provider  organization  or  an  independent  practice 
association.  The  remaining  16%  did  not  have  such 
an  affiliation.  This  information  was  not  indicated 
in  the  1994  study. 

The  patient  volume  from  1994  to  1999  has  seen 
few  changes  as  noted  from  a comparison  of  the 
data.  In  both  years  of  the  surveys,  the  vast  major- 
ity of  patient  encounters  were  in  the  physician's 
office  (eg,  115  and  113  per  week,  respectively). 
Hospital  visits  declined  somewhat  with  the  phy- 
sician encounters  numbering  15  per  week  in  1994 
and  10  per  week  in  1999.  While  39%  of  the  gradu- 
ates reported  following  patients  in  nursing  homes 
in  1994, 24  of  25  (96%)  reported  following  this  type 
of  patients  in  1999.  The  median  number  of  nurs- 
ing home  encounters  was  2 per  week  in  1994  with 
a mean  of  3 per  week  in  1999.  Additionally,  12% 


Table  2 

Approximately  What  Percentage  of  Your  Patients 
Pay  for  Your  Service  in  the  Following  Ways? 


Payment  Method 

1994 

1999 

Medicare 

19.2±15.4 

19.2±9.6 

Medicaid 

23.9±25.2 

12.6±14.9 

Indigent  or  Private  Pay 

10.3±16.6 

1 2.6±1 3.6 

Private  Insurance 
(including  PPO,  IPA) 

32.5±23.3 

44.8±24.3 

Prepaid 

15.6±29.2 

9.8±16.3 

(capitated  at-risk  contract,  HMO) 

The  numbers  indicated  represent  percentase  means  plus/ 
minus  standard  deviation. 


(3/25)  in  1999  indicated  that  they  are  serving  as 
medical  director  of  a nursing  home  facility.  House 
calls  have  remained  a rare  event  from  these  two 
surveys.  However,  a few  physicians  did  report  an 
occasional  house  call  (1994  average  0.3  per  week, 
1999  average  0.5  per  week).  There  was  consider- 
able parallel  concerning  the  pattern  of  managing 
after-hours  calls  which  ranged  widely  in  both  sur- 
veys. In  1994,  24%  reported  having  no  call  respon- 
sibilities; this  number  was  halved  in  1999  at  12% 
with  no  call.  Seven  percent  reported  call  every  fifth 
night  in  1994  while  20%  reported  a similar  call 
schedule  in  1999.  The  most  frequent  call  schedule 
in  both  years  was  call  every  3-4  nights  with  36%  in 
1994  and  40%  in  1999  indicating  such  an  arrange- 
ment. Only  one  reported  call  every  night  or  every 
other  night  in  1994  while  this  was  reported  by  28% 
(7/25)  in  1999. 

Hospital  Privileges 

In  both  surveys,  graduates  were  asked  about 
a selection  of  privileges.  A comparison  of  the  data 
summaries  is  noted  in  Table  3.  In  1994,  89%  of  the 
respondents  felt  that  their  hospital  privileges  were 
"about  right".  This  trend  continues  as  96%  indi- 
cated a similar  sentiment  in  the  most  recent  sur- 
vey. 

The  vast  majority  have  privileges  for  adult 
patients  for  routine  admissions  (83%  in  1994,  92% 
in  1999),  critical  care  (78%  in  1994,  79%  in  1999), 
and  pediatric  routine  admissions  (78%  in  1994, 88% 
in  1999).  Forty-four  (44%)  indicated  privileges  in 


J La  State  Med  Soc  VOL  152  January  2000  37 


Table  3 

Do  You  Have  Hospital  Privileges  for  Patients  Classified  in  the  Following  Manner? 


Yes 

1994 

No 

Yes 

1995 

No 

Adult  Medicine 

(routine  admissions) 

83 

17 

92 

8 

Adult  critical  care 
(ICU,  CCU) 

78 

22 

79 

21 

Pediatrics  (routine  admissions) 

78 

22 

88 

12 

Pediatrics  critical  care  (ICU) 

44 

56 

54 

46 

Routine  OB  care 

22 

78 

8 

92 

High  risk  OB  care 

17 

83 

8 

92 

Caesarean  section 

0 

100 

4 

96 

Forceps  or  vacuum  deliveries 

11 

89 

8 

92 

Oxytocin  induction 

17 

83 

8 

92 

Postpartum  tubal  ligation 

0 

100 

4 

96 

Surgery,  first  assistant 

44 

56 

33 

67 

Primary  surgeon  appendectomy 

0 

100 

0 

100 

Esophagogastroduodenoscopy 

17 

83 

45 

55 

Colonoscopy 

28 

72 

20 

80 

All  numbers  represent  percentages. 


pediatric  intensive  care  in  1994,  while  this  in- 
creased slightly  in  1999  to  54%.  Privileges  for  first 
surgical  assistant  declined  from  44%  in  1994  to  33% 
in  1999. 

The  privilege  rate  for  routine  obstetrical  care 
revealed  a rather  sharp  decline  between  the  two 
surveys.  While  22%  held  such  privileges  in  1994, 
by  1999  this  figure  has  dramatically  declined  to 
only  8%.  A similar  decline  was  noted  in  the  care  of 
high-risk  obstetrical  patients,  although  the  decline 
was  not  quite  as  dramatic  (17%  and  8%).  The  only 
increase  referable  to  obstetrical  care  is  relative  to 
privileges  for  Caesarean  section  and  post-partal 
tubal  ligation.  In  1994,  there  were  no  graduates 
who  had  attained  such  privileges,  yet  in  1999,  one 
respondent  has  done  so  representing  4%  of  the 
total.  While  only  two  physicians  indicated  the  on- 
going acceptance  of  new  OB  patients  in  the  latest 
survey,  this  represents  a decline  of  one  from  the 
previous  survey  in  which  three  physicians  indi- 
cated this  offering.  This  is  consistent  with  findings 
from  the  1994  survey  in  which  one  of  the  three 
physicians  performing  OB  indicated  that  there 
were  plans  to  discontinue  this  practice. 


Patient  Characteristics 

A number  of  questions  about  the  kinds  of  pa- 
tients served  by  our  graduates  were  included  in 
the  survey.  Graduates  were  asked  to  estimate  the 
percentage  of  their  patients  in  a variety  of  age 
groups.  In  a complete  parallel  to  the  first  study, 
the  vast  majority  of  the  respondents  indicated  serv- 
ing patients  of  every  age  group.  In  a comparison 
between  the  groups,  the  characteristics  did  not 
change  very  much  from  one  survey  to  the  next. 
Patients  between  the  ages  of  18  and  65  made  up 
40%  of  the  patient  population  in  1994,  while  in  1999 
this  same  age  group  represented  44%  of  the  total. 
Patients  over  65  years  old  constituted  approxi- 
mately 25%  of  the  1994  survey  while  this  was  21% 
of  the  1999  survey.  In  addition,  patients  less  than 
12  years  old  made  up  21%  and  22%  of  the  1994 
and  1999  survey,  respectively.  The  age  group  be- 
tween 12  and  18  constituted  14%  of  the  practice  in 
1994  and  13%  in  1999. 

Both  questionnaires  asked  about  the  care  of 
patients  with  human  immunodeficiency  virus 
(HIV)  infection.  In  1994,  about  one  third  of  the 
physicians  reported  managing  asymptomatic  pa- 


38  J La  State  Med  Soc  VOL  1 52  January  2000 


tients  with  HIV  infection,  while  in  1999  only  16% 
indicated  caring  for  this  type  of  patient.  Only  2 
(11%)  indicated  that  they  managed  symptomatic 
patients  with  HIV  infection  in  1994.  However,  the 
number  of  1999  respondents  indicating  that  they 
were  managing  the  symptomatic  HIV  patient  was 
zero. 

Graduates  were  also  asked  to  estimate  the 
percentage  of  their  patients  who  fell  into  various 
minority  groups.  Here,  the  estimates  ranged 
widely  from  physician  to  physician  in  both  sur- 
veys. Some  reported  no  minorities  in  their  prac- 
tice. Others  reported  a practice  almost  completely 
made  up  of  one  or  the  other  ethnic  group.  African 
Americans  made  up  over  30%  of  the  patients.  The 
findings  were  consistent  from  the  previous  study 
to  the  present.  The  "average"  practice  in  1994 
would  have  5%  Hispanic,  39%  African- American, 
3%  Asian  patients  with  the  majority  of  the  remain- 
der white.  The  "average"  practice  in  1999  would 
have  3%  Hispanic,  33%  African-American,  1% 
Asian  with  nearly  the  entire  remainder  (62%)  made 
up  of  white  patients. 

Personal  Satisfaction  with  Practice 

Table  4 presents  the  graduates'  ratings  of  sat- 
isfaction with  their  career  on  a scale  of  1 (very  dis- 
satisfied) to  5 (very  satisfied).  On  the  average,  the 
respondents  reported  being  satisfied  with  their 
choice  of  career  in  medicine  in  both  survey  years 
with  a mean  of  4.3  in  1994  and  a mean  of  4.36  in 


Table  4 

Satisfaction  in  Choice  of  Career 


1994 

1999 

Choice  of  medicine 
as  a career 

4.3±0.69 

4.36±0.95 

Choice  of  family  practice 
as  career 

4.3±0.59 

4.36±0.99 

Integration  of  career 
and  other  life  goals 

3.7±0.91 

4.00±0.96 

Current  practice 
arrangements 

3.9±0.90 

4.00±1 .08 

All  numbers  represent  means  plus/minus  standard  deviation. 

These  questions  utilize  Likert  scale  ratinss  from  1 (very 
dissatisfied)  to  5 (very  satisfied). 


1999.  In  addition,  the  indication  was  that  the  gradu- 
ates were  satisfied  with  their  choice  of  family  prac- 
tice as  a specialty  with  similar  numbers  as  before 
(4.3  in  1994  and  4.36  in  1999).  None  reported  being 
dissatisfied  (rating  of  1 or  2)  with  medicine  or  fam- 
ily practice  as  a career  in  either  survey. 

On  the  average,  the  graduates  were  also  sat- 
isfied with  the  integration  of  career  with  other  life 
pursuits  in  both  surveys.  In  fact,  the  level  of  satis- 
faction has  increased  from  a mean  of  3.7  in  1994  to 
a mean  of  4.0  in  1999.  This  trend  was  also  noted  in 
satisfaction  with  current  practice  arrangements 
(mean  3.9  in  1994,  4.0  in  1999).  The  vast  majority 
(89%  in  1994,  88%  in  1999)  reported  that  their  sat- 
isfaction with  their  choice  of  medical  career  has 
remained  about  the  same  or  increased.  Only  two 
(11%)  in  1994  and  three  (12%)  in  1999  reported  that 
their  satisfaction  has  declined. 

DISCUSSION 

The  results  of  the  first  study  performed  in  1994 
suggested  that  the  Lafayette  Family  Practice  Resi- 
dency Program  was  meeting  its  goals  of  training 
family  physicians  to  practice  in  Louisiana  commu- 
nities of  all  sizes.  Subsequent  to  that  study,  it  was 
the  feeling  of  this  residency  program  that  we  were 
in  fact  performing  better  than  this  stated  objective. 
It  was  hoped  that  this  residency  program  was  pref- 
erentially preparing  family  physicians  to  practice 
in  the  more  needy  areas  of  our  state,  ie,  those  with 
smaller  communities  with  fewer  physicians. 

This  second  5-year  follow-up  study  was  un- 
dertaken to  complement  our  previous  work  and 
to  identify  the  trends  in  our  graduates.  It  does  ap- 
pear from  the  results  of  this  1999  survey  that  we 
are  preparing  family  physicians  for  smaller  com- 
munities. The  vast  majority  (92%)  of  our  gradu- 
ates are  not  only  practicing  in  Louisiana  as  family 
physicians,  sixty  percent  (60%)  are  practicing  in 
communities  that  have  populations  of  25,000  or 
less.  This  60%  represents  a substantial  improve- 
ment from  1994  in  which  this  percentage  was  only 
33%  of  the  respondents.  (This  is  also  considerably 
better  than  the  28.8%  figure  that  is  indicated  by 
the  1993  American  Academy  of  Family  Physicians 
Computer  Usage  and  Community  Information  and 
Current  Fees.)  Our  residency  program  is  accom- 
plishing one  of  its  goals. 

Few  other  changes  were  uncovered  from 
the  previous  survey.  Similar  to  the  1994  survey. 


J La  State  Med  Soc  VOL  152  January  2000  39 


the  majority  of  reimbursements  derive  from  tradi- 
tional fee-for-service  arrangements  (private  pay. 
Medicare /Medicaid),  but  many  derive  income 
from  various  sources.  It  is  interesting  to  note  that 
private  insurance  patients  represent  an  increase  of 
12  percentage  points  from  1994  to  1999  (33%  to 
45%).  This  increase  was  equal  to  the  decline  in 
patients  with  Medicaid  (24%  in  1994  and  12%  in 
1999).  The  reasons  for  this  occurrence  is  not  clear 
at  this  time  and  could  not  be  determined  by  the 
available  data. 

As  indicated  in  both  surveys,  it  is  demon- 
strated that  hospital  privileges  are  "about  right" 
and  are  remaining  stable.  An  encouraging  trend  is 
the  marked  increase  in  privileges  for 
esophagogastroduodenoscopy  (17%  in  1994  and 
45%  in  1999).  One  rather  disappointing  trend  that 
was  realized  in  the  comparison  of  the  two  surveys 
is  the  decline  in  obstetrical  practice  among  our 
graduates.  This  tendency  certainly  is  a multifacto- 
rial problem  which  should  be  addressed.  Family 
physicians  are  trained  to  administer  care  to  the 
entire  family.  This  should  include  obstetrical  care 
at  some  level. 

It  does  appear  from  both  surveys  that  the  re- 
spondents are  caring  for  patients  throughout  the 
age  spectrum.  This  does  represent  the  intent  of  the 
family  physician  and  as  such  this  goal  has  been 
attained. 

The  graduates  of  our  program  continue  to 
express  satisfaction  with  their  careers  as  family 
physicians.  One  aspect  of  the  surveys  that  deserves 
emphasis  is  that  even  though  the  majority  of  the 
graduates  are  in  smaller  communities,  the  after- 
hours  call  appears  to  be  manageable  in  both  1994 
and  1999.  This  would  suggest  that  conditions  in 
smaller  communities  with  call  arrangements  lend 
themselves  to  satisfactory  integration  of  career  and 
family.  In  addition,  the  vast  majority  are  either 
satisfied  or  very  satisfied  in  both  surveys  with  very 
similar  numbers.  No  one  expressed  dissatisfaction 
with  his  or  her  choice  in  medicine  in  general  or 
family  practice  in  particular.  This  was  a consistent 
finding  in  1994  and  1999.  Similar  to  the  1994  sur- 
vey, the  few  that  expressed  dissatisfactions  seemed 
to  be  referring  to  particular  practice  arrangements 
or  challenges  integrating  their  careers  and  personal 
lives.  The  reported  data  certainly  seemed  to  indi- 
cate that  after-hour  call  arrangements  were  quite 
satisfactory.  Our  feeling  has  not  changed  since  1999 


that  satisfaction  is  very  important  in  retaining  phy- 
sicians in  their  chosen  careers.  The  satisfaction  ex- 
pressed by  our  graduates  in  both  1994  and  1999 
makes  us  very  optimistic  about  the  retention  of 
these  family  physicians  in  the  kinds  of  practices 
and  locales  where  they  are  needed,  ie,  south  Loui- 
siana communities  in  general  and  smaller  commu- 
nities in  particular. 

The  findings  from  these  two  surveys  engen- 
der a feeling  of  accomplishment  within  our  resi- 
dency program  and  will  serve  to  inspire  our  con- 
tinued efforts  to  supply  Louisiana  communities 
with  much  needed  family  physicians. 

REFERENCES: 

1.  Jones  GN,  Rees  AC.  Lafayette's  Family  Practice 
Residency  Program:  practice  patterns  of  graduates.  J La 
State  Med  Soc.  1996;148:359-363. 


Dr  LeBlanc  is  Resident  Program  Director  of  the  Department  of  Family 
Practice  at  Louisiana  State  University  Health  Services  Center 

in  Lafayette,  Louisiana. 

Mr  Jones  is  Associate  Professor  in  the  Department  of  Family  Medicine  at 
Louisiana  State  University  Health  Services  Center 
in  New  Orleans,  Louisiana. 


40  J La  State  Med  Soc  VOL  1 52  January  2000 


QUADRICEPS  SPARING  MYOPATHY 


Timothy  J.  Dozier,  MD;  John  Kalmar,  MD 

Magnetic  resonance  imaging  (MRI)  has  been  proven  to  be  a useful  tool  in  the  evaluation  of  myopathy. 
Myopathic  changes  secondary  to  processes  such  as  inflammatory  disease,  neuropathy,  and  neuromuscu- 
lar disorders  often  involve  several  muscle  groups.  We  describe  a unique  case  of  lower  extremity  myopa- 
thy with  sparing  of  the  quadriceps  muscle  group  on  MRI  evaluation. 


The  use  of  magnetic  resonance  imaging  (MRI) 
in  the  evaluation  of  soft  tissue  abnormali- 
ties, including  the  evaluation  of  myopathy, 
is  widespread.  The  ability  of  MRI  to  delineate  and 
evaluate  myopathic  changes  in  muscle  groups  is 
excellent.  Myopathic  changes  affecting  skeletal 
muscle  have  many  different  etiologies,  including 
inflammatory  disease,  granulomatous  disease,  and 
neuromuscular  disorders.  The  pattern  of  myo- 
pathic change  often  involves  several  muscle 
groups,  and  in  this  case  MRI  is  used  to  delineate  a 
unique  pattern  of  myopathic  change  affecting  the 
muscle  groups  of  the  lower  extremity. 

CASE  REPORT 

A 45-year-old  man  complained  of  a 4-  to  5- 
year  history  of  progressive  lower  extremity  muscle 
weakness.  On  initial  presentation,  he  demon- 


strated weakness  in  the  iliopsoas  muscle  groups 
bilaterally  (+1  / 5)  and  the  hamstring  muscle  groups 
bilaterally  (+2/5).  No  weakness  was  detected  in 
the  quadriceps  muscle  group  bilaterally  (+5/5)  or 
in  his  upper  extremities.  His  past  medical  history 
was  significant  for  sarcoid,  asthma,  hypertension, 
and  diabetes. 

Electromyographic  findings  indicated  poly- 
myositis. Muscle  biopsy  demonstrated  areas  of 
dense  endomysial  inflammation  with  associated 
myopathic  changes.  These  findings  suggested  an 
inflammatory  myopathy,  and  the  dense  focal  na- 
ture of  the  inflammation  suggested  a granuloma- 
tous myositis  such  as  sarcoidosis.  MRI  of  the  lower 
extremities  revealed  myopathic  changes  in  several 
muscle  groups.  Although  radiological  findings 
were  consistent  with  a generalized  myopathy  of 
the  lower  extremities,  the  quadriceps  muscle 


J La  State  Med  Soc  VOL  1 52  January  2000  4 1 


groups  were  spared  bilaterally.  Figure  la  (T1  axial) 
and  lb  (coronal  short  tau  inversion  recovery)  dem- 
onstrate diffuse  fatty  replacement  and  atrophy  in- 
volving several  muscle  groups  of  the  lower  ex- 
tremities; however,  the  quadriceps  and  gracilis 
muscle  groups  are  spared  bilaterally.  The  imag- 
ing findings  of  inflammatory  myopathy  with  quad- 
riceps and  gracilis  sparing  is  an  interesting  clini- 
cal and  radiographic  finding. 

DISCUSSION 

The  only  references  to  quadriceps  sparing 
myopathy  in  our  literature  search  are  related  to  a 
familial  and  hereditary  inclusion  body  myopathy, 
predominately  seen  in  the  Iranian  Jewish  popula- 
tion.1"3 These  patients  demonstrated  rimmed  vacu- 
oles on  muscle  biopsy.  Our  patient  did  not  fit  into 
this  category. 

We  do  not  have  a definitive  pathological  di- 
agnosis for  our  case;  however,  it  is  interesting 
nonetheless  from  an  imaging  standpoint.  Quadri- 
ceps sparing  myopathy  is  an  extremely  rare  find- 
ing and,  as  previously  mentioned,  only  described 
in  relation  to  inclusion  body  myopathy,  which  this 
patient  did  not  demonstrate  on  biopsy.  Several 
potential  causes  of  our  patient's  myopathy  include 
sarcoid  myopathy,  polymyositis,  diabetic  neuropa- 
thy, neuromuscular  disorders,  or  a combination  of 
these  disease  entities. 

REFERENCES 

1.  Argov  Z,  Yarom  R.  "Rimmed  vacuole  myopathy" 
sparing  the  quadriceps.  A unique  disorder  in  Iranian 
Jews.  / Neurol  Sci  1984;64:33-43. 

2.  Sadeh  M,  Gadoth  N,  Hadar  H,  et  al.  Vacuolar  myopathy 
sparing  the  quadriceps.  Brain  1993;116:217-232. 

3.  Sivakumar  K,  Dalakas  MC.  The  spectrum  of  familial 
inclusion  body  myopathies  in  13  families  and  a 
description  of  a quadriceps-sparing  phenotype  in  non- 
Iranian  Jews.  Neurology  1996;47:977-984. 


Figure  la.  T1  axial  image  demonstrates  diffuse  fatty 
replacement  and  atrophy  involving  several  muscle  groups  of 
the  lower  extremities  with  sparing  of  the  quadriceps  and 
gracilis  muscle  groups  bilaterally. 


Figure  1b.  Coronal  short  tau  inversion  recovery  demonstrates 
diffuse  fatty  replacement  and  atrophy  involving  several  muscle 
groups  of  the  lower  extremities  with  sparing  of  the  quadriceps 
and  gracilis  muscle  groups  bilaterally. 


Dr  Dozier  is  a resident  in  the  Department  of  Radiology  of  Ochsner  Clinic 
and  Alton  Ochsner  Medical  Foundation  in  New  Orleans,  Louisiana. 


Dr  Kalmar  is  a radiologist  with  Ochsner  Clinic  and  Alton  Ochsner 
Medical  Foundation  in  New  Orleans,  Louisiana. 


42  J La  State  Med  Soc  VOL  152  January  2000 


CALENDAi 


FEBRUARY  2000 


6- 8  Symposium  on  E-Healthcare  Strategies  for 

Physicians,  Hospitals  & Integrated  Delivery 
Systems 

Scottsdale,  AZ.  Contact:  Linda  Jenkins, 
coordinator;  phone:  (760)  771-5102;  fax: 
(760)  771-3183;  e-mail:  lindaihi@aol.com. 

7- 9  11th  Annual  Rural  Health  Policy  Institute 

Washington  D.C.  Contact:  Elizabeth  Briggs, 
National  Rural  Health  Association, 
Government  Affairs;  phone:  (202)  232- 
6200;  e-mail:  briggs@NRHArural.org; 
Internet:  www.NRHArural.org. 

18-19  6th  Annual  Patrick  Hanley  Colorectal 
Surgery  Symposium 

New  Orleans,  LA.  Contact:  Brandi  Orgeron, 
Alton  Ochsner  Medical  Foundation;  phone: 
(800)  778-9353;  fax  (504)  842-4805;  e- 
mail:  borgeron@ochsner.org 

20-25  Advances  in  Imaging:  2000 

Breckenridge,  CO.  Contact:  Shirley  K. 
Cospolich,  Tulane  University  Medical  Center, 
Center  for  Continuing  Education  TB5 1 , 1 430 
Tulane  Ave.,  New  Orleans,  A 701 1 2-2699; 
phone:  (504)  588-5466,  (800)  588-5300; 
fax:  (504)  584-1779. 

25-27  Prevention  of  Violence:  The  Role  of  the 
Physician 

Baton  Rouge,  A.  Contact:  Pamela  Schmidt, 
Tulane  University  Medical  Center,  Center  for 
Continuing  Education  TB51,  1430  Tulane 
Ave.,  New  Orleans,  A 701 1 2;  phone:  (504) 
588-5466,  (800)  588-5300;  fax:  (504)584- 
1779. 


MARCH  2000 


4-6  15th  Annual  Mardi  Gras  Anesthesia 
Update 

New  Orleans,  A.  Contact:  Judy  Lua 


Esporotu,  Tulane  University  School  of 
Medicine,  1430  Tulane  Ave.,  New  Orleans, 
A 70112;  phone:  (800)  588-5300,  (504) 
588-5466;  e-mail:  cme@tulane.edu. 

14-17  12th  National  HIV/AIDS  Update 
Conference:  HIV/AIDS  at  the  Crossroads- 
Confronting  Critical  Issues 

San  Francisco,  CA.  Contact:  American 
Foundation  for  AIDS  Research  (amfAR); 
Internet:  www.amfar.org/nauc. 

29-2  2000  International  Conference  on  Physi- 

cian Health:  “Recapturing  the  Soul  of 
Medicine" 

Charleston,  SC.  Contact:  Roger  Brown,  PhD, 
AMA  Science  and  Public  Health  Advocacy 
Programs,  phone:  (800)  621-8335,  (312) 
464-5066;  fax:  (312)  464-5841. 


April  2000 


10-14  29th  Family  Practice  Update 

New  Orleans,  LA.  Contact:  Kathleen 
Melancon,  Louisiana  State  University  School 
of  Medicine  Institute  of  Professional 
Education;  phone:  (504)  568-5272;  e-mail: 
cme@lsumc.edu. 

27-29  10th  Annual  Endocrinology  Update 

New  Orleans,  A.  Contact:  Jocelyn  Arnold, 
Alton  Ochsner  Medical  Foundation;  e-mail: 
jarnold@ochsner.org;  phone:  (504)  842- 
3702. 

29-30  Annual  Tri-State  Anesthesiology 
Conference 

New  Orleans,  A.  Contact:  Jocelyn  Arnold, 
Alton  Ochsner  Medical  Foundation;  e-mail: 
jarnold@ochsner.org;  phone:  (504)  842- 
3702. 


« 


J La  State  Med  Soe  VOL  1 52  January  2000  43 


LSMS  MEETINGS 


FEBRUARY  1 999  MARCH  1 999 


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8:30  a.m. 

9-13  Washinston  Mardi  Gras 

Washington  D.C. 

25-28 

AMA  Leadership  Conference 
Miami,  FL 

18  Disaster  and  EMS  Committee 
10:00  a.m. 


(Unless  indicated  otherwise , all  meetings  are  at  the  LSMS  Headquarters.) 


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To  reach  your  local  office, 
call  1-800-344-1899. 

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J La  State  Med  Soc  VOL  1 52  January  2000  45 


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relays  up-to-the-minute  bulletins  and  Calls  to  Action  during  the 
Legislative  Session  and  other  pertinent  times  during  the  course  of  the 
year,  via  the  LSMS  website,  www.lsms.org,  or  the  use  of  blast  fax  and 
e-mails.  These  are  designed  to  keep  members  informed  and  involved 
in  the  issues  that  directly  affect  them  and  the  well-being  of  their 
patients. 


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Blood  Mercury  Levels  & Fish  Consumption  in  Louisiana 
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Louisiana  Parish  Health  Profiles  1999:  Using  Information  To  Drive  Local  Action 
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Utilizing  our  new  Vista  Polaris  MRI  with 
27  mT  PowerDrive  gradients,  some  of  the  most 
powerful  gradients  currently  approved  by  the 
FDA,  peripheral  MR  Angiography  studies  of  the 
lower  extremities  are  greatly  improved  and  can 
serve  as  an  alternative  to  invasive  conventional 
angiography.  Medicare  now  provides 
coverage  and  has  approved  MRA 
as  an  appropriate  test  in  determining 
the  extent  of  peripheral  vascular 
disease  in  the  lower  extremities* 
Additionally,  MRA  has  been  shown  to  find 
occult  flow  in  blood  vessels  where  it  was  not 
apparent  on  conventional  angiography. 

MRA  is  a non-invasive  test  and  requires 
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NOW  OPEN  - AVENUE  C/ MARRERO  LOCATION 


Editor 

CONWAY  S.  MAGEE,  MD 

Chief  Executive  Officer 

DAVE  TARVER 

General  Manager 

CATHY  LEWIS 


Managing  Editor 

ANNE  SHIRLEY 


Administrative  Assistant 

MELISSA  CANTRELL 

Advertising  Sales 

ANNE  GOOCH 

BOARD  OF  TRUSTEES 
Chairman,  CONWAY  S.  MAGEE,  MD 
K.  BARTON  FARRIS,  MD 
EMILE  K.  VENTRE  JR,  MD 
Ex  officio,  C.  Clinton  Lewis,  MD 

EDITORIAL  BOARD 
A.  JOANNE  GATES,  MD 
RODNEY  C.  JUNG,  MD 
PATRICK  W.  PEAVY,  MD 
TRENTON  L.  JAMES  II,  MD 
JACK  P.  STRONG,  MD 
CLAY  A.  WAGGENSPACK  JR,  MD 
WINSTON  H.  WEESE,  MD 

LSMS  BOARD  OF  GOVERNORS 
C.  CLINTON  LEWIS,  MD 
DUDLEY  M.  STEWART,  MD 
KEITH  DESONIER,  MD 
LEO  L.  LOWENTRITT  JR,  MD 
K.  BARTON  FARRIS,  MD 
RUSSELL  C.  KLEIN,  MD 
WALLACE  H.  DUNLAP,  MD 
VINCENT  A.  CULOTTA  JR,  MD 
RICHARD  J.  PADDOCK,  MD 
BARRY  G.  LANDRY,  MD 
WILLIAM  T.  HALL,  MD 
JOSEPH  BUSBY  JR,  MD 
LYNN  Z.  TUCKER,  MD 
R.  MARK  WILLIAMS,  MD 
MARTIN  B.  TANNER,  MD 
MARTIN  J.  DUCOTE  JR,  MD 
MARCUS  L.  PITTMAN  III,  MD 
CHARLES  D.  BELLEAU,  MD 
JOSHUA  LOWENTRITT,  MD 
LAURA  BRESNAHAN 

ESTABLISHED  1844.  Owned  and  edited  by 
The  Journal  of  the 
Louisiana  State  Medical  Society,  Inc., 
6767  Perkins  Road,  Baton  Rouge,  LA  70808; 
phone:  (225)  763-2310;  fax  (225)  763-2332. 

e-mail:  publicaffairs@lsms.org 
Internet:  www.lsms.org 

Copyright  2000  by  The  Journal  of  the 
Louisiana  State  Medical  Society,  Inc. 

Subscription  price  is  $35  per  year  in  advance, 
postage  paid  for  the  United  States; 
$50  per  year  for  all  foreign  countries 
belonging  to  the  Postal  Union. 

Advertising:  Contact  Anne  Gooch, 
6767  Perkins  Road,  Baton  Rouge,  LA  70808; 
(225)  763-2310  or  at  (504)  895-5189,  in  New  Orleans. 

Postmaster:  Send  address  changes  to 
6767  Perkins  Road,  Baton  Rouge,  LA  70808. 

The  Journal  of  the  Louisiana  State  Medical  Society 

(ISSN  0024-6921)  is  published  monthly 
at  6767  Perkins  Road.  Louisiana  State  Medical  Society, 
Baton  Rouge,  LA  70808. 
Periodical  postage  paid  at  Baton  Rouge,  LA 
and  additional  mailing  offices. 

Articles  and  Advertisements  published  in  the  Journal 
are  for  the  interests  of  its  readers  and  do  not 
necessarily  represent  the  official  position  or 
endorsement  of  The  Journal  of  the  Louisiana 
State  Medical  Society,  Inc.  or  the 
Louisiana  State  Medical  Society. 

The  Journal  reserves  the  right  to  make  the  final 
decision  on  all  contents  and  advertisements. 


Of  the  Louisiana  State  Medical  Society 


Special  Issue 

- . 

: Public 

:l£8  — — — — - 

HEALTH  IN  LOUISIANA 

Elizabeth  T.H.  Fontham,  DrPH 

63 

PUBLIC  HEALTH  IN  LOUISIANA: 
AN  INTRODUCTION 

Trade  M.  Bellanger,  BA 
Erica  M.  Ceasar,  MSPH 
Louis  Trachtman,  MD,  MPH 

64 

BLOOD  MERCURY  LEVELS  AND 
FISH  CONSUMPTION  IN  LOUISIANA 

Louis  Trachtman,  MD,  MPH 
Bobby  Savoie,  MPH 

74 

ARE  YOU  SANITARY? 

Kim  B.  Overstreet,  MA 

78 

PUBLIC  HEALTH  EDUCATION  OPPORTUNITIES 
FOR  PHYSICIANS  IN  LOUISIANA 

Liz  Sumrall,  MPA 
Kate  McCaffery,  MPH 
Madeline  Roberts,  MPH 
Elisabeth  Gleckler,  MPH 

83 

LOUISIANA  PARISH  HEALTH  PROFILES 
1999:  USING  INFORMATION  TO  DRIVE 
LOCAL  ACTION 

Alice  LeBlanc,  MPH 

89 

LOUISIANA  RURAL  HEALTH  ACCESS  PROGRAM 

PARTMENTS 

50 

INFORMATION  FOR  AUTHORS 

C.  Clinton  Lewis,  MD 

52 

PRESIDENT’S  MESSAGE 
2000  Legislative  Session 

Mrs  Karen  Depp 

55 

LSMS  ALLIANCE 

LSMSA  Website  Bursts  Onto  the  Scene 

Jorge  1.  Martinez-Lopez,  MD 

56 

ECG  OF  THE  MONTH 
Sinister  Implications 

Gustavo  A.  Colon,  MD 

59 

THE  JOURNAL  150  & 100  YEARS  AGO 
February  1850  and  1900 

94 

CALENDAR 

96 

CLASSIFIED  ADVERTISING 

Journal 


Eugene  New 
New  Orleans 

J La  State  Med  Soc  VOL  152  February  2000  49 


* - 

6ft,  Jfe 


Information  for  Authors 


The  Journal  is  published  for  the  benefit  of  the  members  of  the  Louisiana  State 
Medical  Society.  Manuscripts  should  be  of  interest  to  a broad  spectrum  of 
physicians  and  designed  to  provide  practical  information  on  the  current  status 
and  the  progress  and  changes  in  the  field  of  clinical  medicine.  The  articles 
published  are  primarily  original  scientific  studies  but  may  include  societal, 
socioeconomic,  or  medicolegal  topics. 

Review  Process 

Each  submission  is  reviewed  by  the  editor  and  is  subject  to  peer  review  by  one 
of  the  editorial  consultants.  Manuscripts  are  also  subject  to  editorial  revision 
and  to  such  modification  as  to  bring  them  into  conformity  with  Journal  style. 
The  final  decision  to  accept  or  revise  falls  to  the  editor. 

Preparation  of  the  Typescript 

Allow  margins  of  at  least  1 inch  on  all  sides;  avoid  end-of-line  hyphens;  num- 
ber all  pages,  starting  with  the  title  page;  begin  each  major  part  of  the  manu- 
script on  a new  page;  double-space  all  parts  of  the  manuscript.  Submit  the 
manuscript  in  triplicate. 

Computer  Disk 

When  the  manuscript  has  been  accepted,  the  author  will  be  asked  to  submit  a 
3.5”  diskette  with  language  exactly  matching  that  of  the  accepted  version. 

Style  Conventions 

Units  of  measure.  Use  conventional  units.  If  essential,  SI  units  may  be 
added  in  parentheses  immediately  following  the  conventional  expression. 

Drug  names.  Use  the  generic  form.  If  the  proprietary  name  is  relevant  to 
the  study,  it  may  be  added  in  parentheses  immediately  following  the  first  men- 
tion of  the  generic  name.  A generic  name  is  lowercased;  a proprietary  name  is 
capitalized. 

Citing  a reference  entry.  Use  superior  arabic  numerals  placed  at  the 
logical  site  in  the  sentence;  insert  immediately  after  a word  or  mark  of  punc- 
tuation; set  close.  Cite  in  the  main  text,  in  tables,  and  in  the  legends  for 
illustrations;  do  not  cite  in  the  abstract. 

Parts  of  the  Manuscript 

Title  page.  The  title  page  should  carry  the  following  information:  (1) 
The  title  of  the  manuscript,  which  should  be  concise  but  informative.  (2)  The 
full  name  of  each  author  together  with  his  highest  academic  degree  relevant 
to  the  subject  matter  of  the  paper.  List  authors  in  the  order  of  the  magnitude 
of  their  contribution.  List  as  authors  only  those  who  have  contributed  mate- 
rially to  the  conduct  of  the  study  or  to  the  preparation  of  the  manuscript.  (3) 
The  affiliation  of  each  author  at  the  time  die  study  was  done.  (4)  Explanatory 
notes  that  give  (a)  a brief  biographical  note  for  each  author  indicating  his 
academic  appointments,  hospital  affiliations,  and  practice  location;  and  (b) 
the  name  and  address  of  the  author  to  whom  requests  for  reprints  should  be 
addressed  or  a statement  that  reprints  will  not  be  available. 

Abstract  and  Keywords.  Give  a brief  recapitulation  of  the  purpose  of 
the  paper,  the  methods  and  subjects  used,  the  results,  and  die  conclusions; 
avoid  acronyms  and  abbreviations,  do  not  cite  sources  listed  in  the  references 
section  (the  abstract  must  stand  alone);  limit  the  abstract  to  150  words. 

On  the  lower  part  of  the  same  page,  list  three  to  five  key  words  or  short 
phrases  that  will  assist  indexers.  Use  terms  from  Medical  Subject  Headings  as 
used  in  Index  Medicus  when  possible. 

Main  Text.  Avoid  highly  technical  expressions  and  jargon;  the  article 
should  be  easily  understood  by  the  general  readership. 

Use  subheads  freely  to  break  the  typographic  monotony,  make  the  paper 
easier  to  read,  and  fortify  the  sequence  of  the  author’s  argument.  Commonly 
used  subheads  are:  introduction  or  background,  methods  and  subjects,  re- 
sults, discussion,  and  conclusions. 

Acknowledgments.  Acknowledgments  must  be  made  for  financial  assis- 
tance (grants,  equipment,  drugs)  and  for  the  use  of  previously  published  ma- 
terial. Acknowledgment  may  be  made  for  technical  assistance  and  intellectual 
participation  in  conducting  the  study  or  preparing  the  manuscript. 

References.  Each  source  cited  in  the  main  text,  tables,  or  legends  must 
be  listed  in  the  references  section;  and,  conversely,  all  entries  in  the  references 
section  must  have  been  cited  in  the  main  text,  tables,  or  legends. 

Each  reference  entry  is  composed  of  three  elements:  (1)  the  name  of  rite 
author,  (2)  the  title  of  the  article  or  book,  and  (3)  die  imprint.  The  following 


three  examples  illustrate  the  reference  style  adopted  by  the  Journal  for  ( 1 i a 
reference  to  an  article  in  a journal,  (2)  a reference  to  a book  or  monograph, 
and  (3)  a reference  to  a part  of  a larger  work. 

1.  Brush  JE  Jr,  Cannon  RO  III,  Schenke  WH,  et  al.  Angina  due  to  coro- 
nary microvascular  disease  in  hypertensive  patients  without  left  ven- 
tricular hypertrophy.  N Engl  J Med  1988;319:1302-1307. 

2.  Hajdu  SI.  Pathology  of  Soft  Tissue  Tumors.  Philadelphia,  Pa:  Lea  & 
Febiger;  1979:60-83. 

3.  Robinson  BH.  Lactic  acidemia.  In:  Scriver  CR,  Beaudet  AL,  Sly  WS, 
et  al  (editors).  The  Metabolic  Basis  of  Inherited  Disease , 6 th  edition. 
New  York:  McGraw-Hill;  1989:869-888. 

Type  each  reference  entry  as  a separate  hanging  paragraph;  number  the  en- 
tries consecutively  in  the  order  cited;  do  not  list  alphabetically;  double-space 
reference  entries;  punctuate  as  shown  in  the  examples  above.  Limit  refer- 
ences to  15  unless  special  arrangements  have  been  made  with  the  editors. 

Tables.  Tables  should  be  self-explanatory  and  supplement,  not  duplicate, 
the  main  text.  All  tables  should  have  been  referred  to  in  the  main  text. 

Type  each  table  on  a separate  page;  number  tables  in  the  order  first  cited; 
provide  a title;  consult  recent  issues  of  the  Journal  for  examples. 

Legends.  Legends  identify  and  describe  the  illustrations.  A legend  con- 
sists of  a figure  number,  a description  of  the  figure,  an  explanation  of  an- 
notations on  the  figure,  the  techniques  used,  and  an  acknowledgment  of  the 
source  if  the  figure  has  been  previously  published. 

Type  legends  together  on  a separate  page;  use  block  paragraphs.  Number 
the  figures  in  the  order  first  cited  in  the  text. 

Illustrations 

All  illustrations  should  be  referred  to  in  the  text.  An  illustration  and  its  legend 
must  stand  alone.  Illustrations  should  be  professionally  prepared.  Four-color 
illustrations  are  acceptable  at  the  author’s  expense. 

Cover  Letter 

The  manuscript  must  be  accompanied  by  a cover  letter  which  (1)  requests 
consideration  of  the  paper  for  publication  in  the  Journal ; (2)  states  that  the 
paper  has  not  been  published  previously  and  is  not  currently  being  considered 
by  another  journal;  (3)  acknowledges  any  potential  conflict  of  interest;  (4) 
states  that  the  final  manuscript  has  been  seen  by  all  of  the  authors;  and  (5) 
designates  one  of  the  authors  as  corresponding  author  and  lists  his  full  mailing 
address,  telephone  number,  and  fax  number. 

Permissions 

Written  permission  must  be  obtained  from  (1)  any  individual  w-ho  is  recog- 
nizable in  text  or  illustration,  (2)  the  copyright  owner  of  any  previously  pub- 
lished matter  (text,  table,  or  figure)  which  is  to  be  incorporated  in  the  manu- 
script, and  (3)  any  individual  mentioned  in  the  acknowledgments. 

Copyright  Transfer 

Authors  will  be  asked  to  sign  a form  transferring  to  the  Journal  copyright 
ownership  of  any  article  accepted  for  publication.  Such  articles  may  not  be 
published  elsewhere,  in  witole  or  in  part,  without  written  permission  from  the 
editors. 

Galley  Proofs 

Galley  proofs  will  be  mailed  to  the  corresponding  author  for  review. 

Editorial  Assistance 

An  expanded  version  of  Information  for  Authors  is  published  in  die  January 
and  July  issues.  For  help  in  preparing  your  manuscript  or  for  questions  about 
the  editorial  process,  write  the  Editor  or  die  Managing  Editor  as  below.  Or, 
contact  the  Editor,  Dr  Magee,  at  (337)  439-8450,  FAX  (337)  439-7576;  e- 
mail:  conwaystonemagee@compuserve.com;  or  the  Managing  Editor,  Anne 
Shirley  at  (225)  763-8500,  FAX  (225)  7 63-2332,  or  e-mail: 
publicaffairs@lsms.org. 

Submission  of  the  Manuscript 

Submit  the  manuscript  (in  triplicate),  the  illustrations  (two  copies  each),  die 
required  permissions,  and  a cover  letter  to: 

Editor,  Journal  of  the  Louisiana  State  Medical  Socict v 
6767  Perkins  Rd. 

Baton  Rouge,  LA  70808 


50  J La  State  Med  Soc  VOL  152  February  2000 


President's  Messaae 

^eP 


As  you  know,  on  November  20  of  last 
year,  the  General  Election  was  held  for 
statewide  and  legislative  races.  I am 
pleased  to  report  that  of  the  135  candidates  the 
Medical  Society  supported  through  LAMPAC, 
124  won.  The  LSMS  is  very  proud  of  this  92% 
success  rate  and  is  excited  about  the  prospect 
of  working  closely  with  the  new  legislature. 

On  April  24,  the  2000  Regular  Legislative 
Session  will  convene  for  a fiscal  only  session 
and  must  adjourn  no  later  than  6:00  pm  on  June 
7.  The  constitution  provides  that,  in  even- 
numbered  years,  the  Legislature  is  restricted 
to  consideration  of  legislation  which  provides 
for  enactment  of  a general  appropriations  bill, 
implementation  of  a capital  budget,  and 
consideration  of  tax  matters.  However,  the 
Governor  may  call  a special  session  in  which 
a limited  number  of  items,  fiscal  or  general, 
may  be  heard  as  determined  by  the  Governor. 
Although  a date  has  not  been  confirmed. 
Governor  Foster  has  stated  that  he  intends  to 
call  a special  session  approximately  one  month 
prior  to  the  regular  session  to  deal  with 
funding  for  teacher  pay  raises. 


You  have  probably  heard  or  read  recent 
reports  advising  that  the  2000-2001  state 
budget  deficit  could  be  as  great  as  $500 
million.  In  late  December,  Department  of 
Health  and  Hospitals  (DHH)  Secretary  David 
Hood  testified  before  the  Joint  Legislative 
Committee  on  the  Budget  that  state 
government  is  facing  a $153  million  shortfall 
in  the  current  1999-2000  Medicaid  budget.  In 
fact,  on  December  7,  1999,  Governor  Foster 
issued  an  Executive  Order  implementing  a 
spending  freeze  throughout  the  executive 
branch  of  state  government  to  achieve  a state 
general  fund  savings  of  at  least  $50  million 
for  the  remainder  of  the  1999-2000  fiscal  year, 
which  ends  June  30,  2000.  Within  the  same 
Executive  Order,  DHH  was  ordered  to  cut 
$22.4  million  from  its  budget  towards  the  $50 
million  total  savings  sought  by  the  Governor. 

It  is  safe  to  say  that  the  primary  focus  of 
the  LSMS  Department  of  Governmental 
Affairs  in  2000  will  be  on  the  state  budget. 
More  specifically,  given  the  dire  financial 
situation  and  predictions,  the  LSMS  will  face 
a colossal  task  to  simply  maintain  the  present 


J La  State  Med  Soc  VOL  152  February  2000  51 


level  of  Medicaid  reimbursement  for  private 
physician  services.  The  administration  has 
publicly  proclaimed  that  its  primary  goal  of  the 
coming  legislative  session  is  to  find  a way  to  raise 
classroom  teacher  pay  to  the  southern  average. 
Given  that  state  income  and  corporate  tax 
collections  appear  to  be  flat,  several  new  or 
increased  taxes  have  been  proposed  to  fund  the 
pay  raises  and  operating  deficit.  In  addition, 
there  has  been  some  discussion  regarding 
removing  some  tax  exemptions  to  raise  revenue. 
However,  at  this  time,  neither  the  Governor  nor 
the  new  leadership  of  the  legislature  has  issued 
any  concrete  proposals  to  solve  the  budget 
deficit.  Of  course,  the  fear  of  the  collective  health 
care  industry  is  that  the  DHH  budget  will  suffer 
serious  cuts  or,  at  a minimum,  no  increased 
funding. 

In  1995,  private  physician  services  were 
budgeted  at  $235  million.  In  1998,  the  budget 
for  private  physicians'  services  had  been 
reduced  to  $193  million.  In  the  current  1999-2000 
fiscal  year,  it  is  estimated  that  DHH  will  expend 
approximately  $211  million  for  private  physician 
services.  Since  1995,  the  budget  for  private 
physician  services  has  suffered  a 9%  reduction, 
while  the  costs  of  providing  health  care  have 
steadily  increased. 

Rural  and  inner  city  physicians  throughout 
the  state  treat  a high  percentage  of  Medicaid 
patients  and,  thus,  rely  heavily  on  reasonable 
Medicaid  payment  rates.  Many  of  these 
physicians  face  the  threat  to  financial  survival 
and  represent  the  health  care  safety  net  for  poor 
patients.  Repeated  reductions  in  payment  rates 
will  continue  to  reduce  access  to  health  care 
statewide  because  fewer  physicians  are  willing, 
or  able,  to  accept  below-cost  reimbursement. 
Medicaid  payments,  on  average,  are  52%  of 
private  sector  reimbursement,  and,  as  such,  are 
below  practice  overhead. 

In  the  1999  Regular  Legislative  Session,  the 
LSMS  achieved  a great  deal  of  success  with  its 
legislative  agenda.  This  success  was  due  in  large 
part  to  the  grassroots  involvement  of  physicians 
across  the  state.  Once  again,  the  LSMS  is  calling 
on  its  membership  to  join  the  advocacy  effort  to 


persuade  the  Legislature  to  keep  physician 
reimbursement  at  a level  that  will  continue  to 
allow  access  to  care  for  our  less  fortunate 
citizens. 

Since  there  is  a significant  number  of  new 
legislators,  now  is  the  time  to  contact  your 
legislators  and  begin  building  a relationship  that 
will  enable  you  to  more  easily  communicate 
during  the  session.  The  LSMS  strongly 
encourages  you  to  offer  to  be  a health  care 
resource  to  as  many  legislators  as  possible.  It's 
never  too  early  to  develop  effective  dialogue 
with  your  elected  officials  who  will  determine 
the  future  state  of  health  care  in  Louisiana. 

Prior  to,  and  during,  the  session,  the  LSMS 
will  post  talking  points,  calls  to  action,  and 
weekly  updates  on  our  web  site.  I encourage  you 
to  regularly  check  the  site  for  information  that 
will  aid  you  in  your  discussions  and 
communications  with  your  legislators.  In 
addition,  please  remember  that  you  may  e-mail 
your  legislator  through  our  Grassroots  Action 
Center  found  on  the  LSMS  web  site. 

Remember  physician  involvement  has 
always  been  the  key  to  our  legislative  efforts  and 
success. 


52  J La  State  Med  Soc  VOL  1 52  February  2000 


At  The  Trust  Company, 

our  officers  art  free  to  invest  in  the  dienfs  best  interest. 


With  many  financial  institutions,  the  way  client's  assets 
are  invested  can  be  influenced  by  existing  relationships 
and  obligations  with  certain  funds  and  portfolios. 

That  is  not  the  case  at  The  Trust  Company  of  Louisiana. 
Our  professionals  are  free  to  think  and  invest  independently 
on  our  client's  behalf  - to  suggest  or  select  investment 


opportunities  based  solely  on  performance  and  stability. 
We  are  a Louisiana  staff  owned,  independent  specialized 
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Don ’t  Miss  Out 

On  These  Important  Publications  ! 


Journal  of  the  Louisiana  State  Medical  Society 
Capsules 

You  receive  a copy  of  each  of  these  publications  monthly.  The 
Journal  is  one  of  the  oldest  established  publications  of  its  kind  in 
the  country.  It  features  scientific  information  on  clinical  trials  and 
treatments,  including  several  special  issues  each  year,  highlighting 
such  topics  as  Heart  Disease,  Cancer  in  Louisiana,  Sports  Medicine 
and  Mental  Illness.  In  addition,  the  March  issue  of  the  Journal  is 
supplemented  by  the  LSMS  Annual  report,  including  highlights  of 
the  Annual  Meeting  of  the  House  of  Delegates.  Capsules  is  the 
monthly  newsletter  of  the  LSMS,  featuring  timely  articles  on  local 
and  national  issues  affecting  organized  medicine  and  physician 
practices,  as  well  as  member  accomplishments  and  regular  columns. 


As  a member  of  the  Louisiana  State  Medical  Society , one  of  the  many  benefits  you 
receive  is  a number  of  important  and  informative  publications,  designed  to  keep  you 
up-to-date  on  the  most  current  information  available  on  issues  and  concerns  of 
physicians.  Here  is  just  a sample  of  our  regular  publications. 


The  annual  LSMS  Membership  and  Resource  Directory 

Your  name  is  listed  in  this  widely-recognized  premier  publication  used  by  more 
than  7,000  physicians,  clinics,  hospitals  and  other  healthcare  and  business 
organizations  around  the  state.  In  addition  to  membership  listings,  this  323-page 
directory  contains  extensive  resource  information  that  makes  it  a must-have  item 
referred  to  throughout  the  year. 


Other  Special  Publications 

Throughout  the  year,  you  receive  a number  of  other  special 
communications  pieces.  These  include  Special  Bulletins  to  inform 
LSMS  members  about  current  issues  of  concern  to  medicine,  such  as 
reimbursement  and  fraud  and  abuse  issues.  In  addition,  the  LSMS 
relays  up-to-the-minute  bulletins  and  Calls  to  Action  during  the 
Legislative  Session  and  other  pertinent  times  during  the  course  of  the 
year,  via  the  LSMS  website,  www.lsms.org,  or  the  use  of  blast  fax  and 
e-mails.  These  are  designed  to  keep  members  informed  and  involved 
in  the  issues  that  directly  affect  them  and  the  well-being  of  their 
patients. 


LSMS  Alliance 


LSMSA  Website  Bursts  Onto  the  Scene 


Mrs  Karen  Depp 


With  much  gratitude  to  the  LSMS 
staff,  and  especially  Cathy  Lewis, 
the  LSMSA  now  has  a state  of  the 
art  (science?)  website  that  is  already  drawing 
positive  comment  from  across  the  country.  We 
are  one  of  the  first  state  Alliances  to  have  a 
comprehensive  site  and  we  are  working  to 
make  it  interactive  and  image-delivering!  Take 
a look  - you  may  see  yourself  right  on  our  page! 

As  I travel  the  state  visiting  with  our 
membership  at  alliance  and  auxiliary  meetings, 
it  becomes  clear  that  "we"  are  ready  to  meet 
the  next  century  head  on  and  well  prepared. 
More  and  more  of  our  members  are  not  only 
computer  proficient,  but  innovative  and 
receptive  to  using  this  venue  as  our  primary 
means  of  communication.  Our  on-line  pub- 
lications can  be  updated  in  a second  rather  than 
months  as  in  the  printed  media.  When  we  read 
a notice,  it  is  now  timely  rather  than  historical! 
I am  hopeful  that  each  of  the  individual 
parishes  will  use  their  web  page  in  new  and 
exciting  ways  that  will  teach  the  rest  of  us  some 
new  tricks.  Once  we  have  gotten  over  the 
hurdle  of  restricted  access  (password-keyed  site 
locations)  we  will  be  able  to  publish  our 


directories  on-line  and  save  a tremendous 
amount  of  time  and  cost  in  the  process.  And  they 
will  always  be  as  current  as  our  most  recent 
information  allows! 

I see  a trend  toward  re-involvement  in  our 
Alliances  and  Auxiliaries  and  I am  planning  to 
build  on  this  as  we  continue  our  re-structuring. 
It  is  an  interesting  observation  that  many  of  those 
things  that  "we  always  do"  are  the  very  things 
that  have  driven  away  members.  When  I speak 
of  a new  system  and  structure,  I see  renewed 
interest  and  participation.  I know  that  when  the 
year  comes  to  a close  we  will  look  back  and  feel 
confident  that  we  have  taken  the  right  path  into 
2000  with  our  plans  and  projects.  We  are  always 
proud  and  honored  to  be  standing  beside  the 
LSMS  helping  to  bring  positive  change  and 
dynamic  leadership  to  "our"  profession. 


Mrs  Depp  is  President  of  the 
Louisiana  State  Medical  Society  Alliance. 


J La  State  Med  Soc  VOL  152  February  2000  55 


ECG  3 1 >i  h 


Sinister  Implications 

Jorge  I.  Martinez-Lopez,  MD 


A 76-year-old  woman  was  hospitalized  following  a syncopal  episode  at  home.  She  was 
taking  oral  propranolol  for  long-standing  hypertension.  The  monitor  rhythm  strip  shown 
below,  taken  on  her  fourth  hospital  day,  consists  of  three  separate  leads  recorded 
simultaneously:  from  top  to  bottom  are  leads  II,  and  III. 


What  is  your  diagnosis? 
Elucidation  begins  on  page  57. 


56  J La  State  Med  Soc  VOL  152  February  2000 


ECG  of  the  Month 
Presentation  is  on  page  56. 

DIAGNOSIS  - Transient  cardiac  standstill 

Examination  of  lead  II  provides  the  best  data 
with  which  to  interpret  the  rhythm  strip.  The 
first  six  cardiac  cycles  in  that  lead  show  regu- 
larly occurring  P waves,  at  a rate  of  100  times  a 
minute.  P waves  in  these  cycles  are  inverted  (P') 
and  originate  from  an  ectopic  focus,  either  in  the 
low  right  atrium  or  in  the  AV  junctional  area, 
with  retrograde  conduction  of  the  electrical  im- 
pulses into  the  atria.  Every  P'  wave  conducts 
into  the  ventricles  with  a short  P'R  interval,  a 
finding  that  suggests  close  proximity  of  the  ec- 
topic supraventricular  focus  to  the  AV  junction. 
Intraventricular  conduction  is  normal,  as  de- 
picted by  the  narrow  QRS  complexes.  T waves 
are  low  and  the  QT  interval  is  normal.  After  the 
sixth  cardiac  cycle  of  the  tracing,  disturbing 
events  occur,  which  portend  sinister  implica- 
tions. First,  these  events  are  triggered  by  an  up- 
right P wave,  with  a P'-P  interval  that  is  much 
shorter  than  previous  P'-P'  intervals.  The  exact 
location  of  the  focus  responsible  for  this  P wave 
is  problematic:  it  could  represent  either  a pre- 
mature sinus  impulse  or  a premature,  ectopic 
atrial  impulse. 

More  worrisome  than  ascertainment  of  the 
location  of  the  atrial  focus  is  the  second  finding. 
The  seemingly  benign,  upright,  premature  P 
wave  effectively  shuts  down  all  subsequent  car- 
diac electrical  activity,  as  manifested  by  the 
pause  that  it  triggers.  The  pause  occurs  abruptly, 
is  unexpected,  and  lasts  about  4.6  seconds,  dur- 
ing which  there  is  no  recorded  atrial  or  ventricu- 
lar activity  (cardiac  standstill).  Eventually,  the 
pause  ends  with  the  late  appearance  of  a tiny  P 
wave,  which  is  significantly  different  in  mor- 
phology and  amplitude  than  all  previous  P 
waves.  The  tiny  P wave  is  very  close  to  the  nar- 
row QRS  that  follows  it;  the  short  PR  interval  of 
less  than  0.06  second  raises  the  possibility  that 
this  P wave  is  not  conducted  into  the  ventricles, 
but  is  dissociated  from  the  ventricular  complex 
that  follows  it.  In  either  case,  the  late  appear- 


ance of  atrial  and  ventricular  activity  signals  the 
resurgence  of  previously  dormant  pacemaker 
activity.  A final  finding  is  the  marked  prolonga- 
tion of  the  QT  interval  (0.48  sec)  recorded  only 
in  this  last  cycle. 

What  are  the  sinister  implications  of  these 
ECG  findings?  Clearly,  two  major  electrical 
problems  are  brought  into  sharp  focus  by  the 
abrupt  appearance  of  the  long  pause.  One  re- 
lates to  the  integrity  of  the  SA  node.  The  absence 
of  sinus  P waves  during  the  pause  suggests  that 
either  the  SA  node  has  stopped  firing  tempo- 
rarily (sinus  arrest)  or  that  it  continues  to  fire, 
but  the  impulses  generated  fail  to  exit  the  SA 
node  and  to  reach  the  atrial  musculature  (SA 
nodal  exit  bloc).  There  being  no  basic  sinus 
rhythm  present  in  the  tracing,  the  distinction 
between  these  two  entities  cannot  be  established 
with  certainty  and  either  one  remains  a diagnos- 
tic possibility. 

The  second  and  perhaps  more  serious  abnor- 
mality found  in  the  tracing  is  the  apparent  de- 
pressed electrical  activity  of  subsidiary  pacemak- 
ers in  the  AV  junction  and  in  the  ventricular 
Purkinje  fibers.  Ordinarily,  when  the  SA  node 
relinquishes  its  role  as  the  dominant  cardiac 
pacemaker,  subsidiary  (secondary)  pacemakers 
in  the  heart  assume  command  and  control  of  the 
ventricular  rate  and  rhythm.  Not  so  in  this  case. 
Subsidiary  pacemakers  failed  to  rise  to  the  oc- 
casion, when  the  pause  was  triggered,  until  a 
long  time  had  elapsed. 

The  patient  had  several  similar  sequences  of 
ectopic  atrial  rhythm  and  abrupt  pauses  trig- 
gered by  upright  premature  P waves  during  her 
hospital  stay.  During  these  brief  episodes,  she 
experienced  dizziness  but  no  syncope.  Although 
propranolol  may  have  contributed  to  the  appear- 
ance of  these  ECG  events,  it  was  excluded  as  the 
major  factor  after  its  administration  was  stopped. 
Her  hypertension  was  managed  with  diuretics 
and  ACE  inhibitors.  Also  excluded  as  potential 
causes  for  the  ECG  abnormalities  were  myocar- 
dial infarction  and  ischemic  heart  disease.  In  the 
absence  of  clinically  recognizable  mechanisms 
responsible  for  the  symptomatic  ECG  abnormali- 
ties, the  sequences  leading  to  cardiac  standstill 


J La  State  Med  Soc  VOL  152  February  2000  57 


were  attributed  to  SA  nodal  dysfunction  (sick 
sinus  syndrome).  A permanent,  dual-chamber 
cardiac  pacemaker  was  implanted. 

The  choice  of  therapy  for  patients  with  symp- 
tomatic SA  nodal  dysfunction  is  relatively 
straightforward,  provided  that  a correlation  be- 
tween the  arrhythmia  and  the  symptoms  is  docu- 
mented. If  this  correlation  does  not  exist,  it  is 
inappropriate  to  implant  permanent  cardiac 
pacemakers  in  these  patients.  By  the  same  to- 
ken, in  patients  with  documented,  symptomatic 
episodes  of  SA  nodal  dysfunction,  pharmaco- 
logic treatment  has  no  place  in  the  management 
of  bradyarrhythmia.  Drugs  which  further  de- 
press either  SA  nodal  function  or  the  inherent 
automaticity  of  subsidiary  pacemakers,  or  both, 
must  be  avoided  at  all  costs.  If  such  drugs  have 
to  be  used,  use  with  caution  and  only  under  the 
protective  umbrella  of  an  implanted  cardiac 
pacemaker. 


Dr  Martinez-Lopez  is  a specialist  in  cardiovascular 
diseases  affiliated  with  the  Cardiology  Service,  Depart- 
ment of  Medicine,  Texas  Tech  University  Health  Sciences 
Center  and  Thomason  General  Hospital  in  El  Paso,  Texas. 


GACHASSIN 
LAW  FIRM 

A LIMITED  LIABILITY  COMPANY 

Devoted  Exclusively  to  the  Legal 
Representation  and 
Counseling  of  the  Health  Care 
Industry 


♦ Health  care  joint  ventures,  mergers 
and  acquisitions 

♦ Regulatory  compliance  and 
governmental  relations 

♦ Fraud  and  abuse/Stark  compliance 

♦ Managed  care  strategies  and 
contracting 

♦ Risk  management  and  medical 
malpractice  defense 

♦ Medicare  reimbursement  and  appeals 


HEALTH  LAW  GROUP: 

Nick  Gachassin,  Jr.  nick@gachassin.com  Nick  Gachassin,  III  nickiii@gachassin.com 

Richard  MacMillan  richard@gachassin.com  Rose  Young  rose@gachassin.com 

Visit  our  web  site  at  wivzv.gachassin.com 


1026  St.  John  Street  • P.O.  Box  2850  • Lafayette,  LA  70502 
Telephone:  (318)  235-4576  • Fax:  (318)  235-5003 


58  J La  State  Med  Soc  VOL  152  February  2000 


Th  jrnal  1 50  & 1 00  Years  Aao 

*:&  


January  1850  and  1900 


Gustavo  A.  Colon,  MD 


Interestingly  enough,  advertisements  for 
medical  schools  were  apparently  common 
place  in  the  19th  Century  in  contrast  to  to- 
day where  the  applications  certainly  exceed  the 
number  of  spots  in  various  medical  schools.  In 
the  19th  Century,  there  were  many  proprietary 
medical  schools  all  seeking  students.  What  fol- 
lows is  an  advertisement  or  sort  of  an  advertorial 
so  to  speak  in  The  Journal  for  the  University  of 
Louisiana's  Medical  School.  As  you  can  see,  to 
induce  students,  they  even  reduced  the  fee  of 
the  tickets  that  each  professor  charged.  Common 
in  those  times  was  not  to  charge  a curriculum 
fee  but  rather  to  charge  a specific  ticket,  very 
much  like  going  to  the  theater,  by  each  profes- 
sor for  appropriate  admission  to  the  lectures. 

"Without  seeking  to  disparage  any  of  the 
many  excellent  medical  schools  scattered 
throughout  the  country,  we  feel  called  upon  to 
advert  in  this  connection  to  the  advantages,  of- 
fered by  this  city  to  the  medical  student,  for  ac- 
quiring a thorough  and  practical  knowledge  of 
his  profession.  With  a faculty  thoroughly  and 
permanently  organized,  with  lecture  rooms  spa- 
cious enough  to  accommodate  five  or  six  hun- 
dred students,  with  cabinets  furnished  with 


models,  drawings,  wax  preparations,  morbid 
specimens,  both  wet  and  dry,  with  a hospital 
handy  by  the  college  hall,  at  all  times  accessible 
to  the  student  and  abounding  in  a great  variety 
of  rare  and  interesting  cases  of  disease,  it  cannot 
be  denied  that  New  Orleans,  with  the  foregoing 
advantages,  holds  out  strong  inducements  to 
those  who  aspire  to  become  practical  physicians. 
The  perfectly  independent  position  which  we 
occupy  in  relation  to  the  medical  department  of 
the  University  of  Louisiana  justifies  this  free  and 
candid  expression  of  opinion  of  its  high  claims 
to  the  patronage  of  the  southern  student.  The  lec- 
tures will  commence  for  the  session,  1849-50,  on 
the  12th  of  November  and  continue  four  months. 
We  see  from  the  circular,  published  by  the  Uni- 
versity, that  the  tickets  of  each  professor,  have 
been  reduced  to  fifteen,  and  the  diploma-fee  to 
thirty  dollars." 

In  the  February  1900  issue  of  The  Journal,  the 
most  interesting  articles  are  in  the  communica- 
tion section  of  the  editorial  page.  The  first  one  is 
written  to  the  members  of  the  profession  by  the 
editor  regarding  a Bill  that  had  been  brought  up 
in  the  District  of  Columbia  to  prohibit  vivisec- 
tion and  to  encourage  passage  of  similar  bills  in 


J La  State  Med  Soc  VOL  152  February  2000  59 


all  State  Legislatures.  It  was  pointed  out  that 
this  would  seriously  interfere  not  only  with  sci- 
entific research  but  also  the  experimental  work 
of  the  Bureau  of  Animal  Industry  and  the  three 
government  services,  the  Army,  Navy,  and 
Marine  hospital  services,  which  could  no  longer 
do  any  type  of  animal  experimental  work.  The 
author  stated  that  one  example  of  the  inesti- 
mable value  of  scientific  research  is  to  prevent 
disease,  and  he  gives  the  example  of  modern 
surgery  and  the  antitoxin  treatment  of  diphthe- 
ria which  was  discovered  through  animal  re- 
search. He  stated  that  it  was  of  the  utmost  im- 
portance that  any  physician  who  read  the  edi- 
torial appeal  immediately  and  communicate 
with  the  Senators  from  the  State  as  well  as  in- 
voke the  aid  of  the  Representatives  in  order  to 
prevent  this  Bill  from  passing. 

The  second  editorial  regards  the  Prosser 
case.  Apparently,  Dr  S S Prosser,  who  formed 
the  "ABBO"  Clinic  in  New  Orleans  and  was 
apparently  a notorious  self-promoter  and  ad- 
vertising physician  of  the  period,  had  been  de- 
nied a license  in  the  State  of  Louisiana.  He  had 
been  found  in  violation  of  the  medical  law  by 
the  Parish  of  Orleans.  It  states  that,  several 
weeks  before  the  meeting  of  the  Board  in  May 
1899,  Dr  Prosser,  a graduate  of  Jefferson  Medi- 
cal College,  applied  for  and  obtained  a tempo- 
rary certificate  to  practice  medicine  in  Louisi- 
ana until  the  next  regular  meeting  of  the  Board. 
Dr  Prosser  then  founded  the  "ABBO"  Clinic, 
apparently  much  to  the  chagrin  of  the  local 
medical  committee.  On  the  day  that  the  Board 
met  in  session.  Dr  Prosser  did  not  present  him- 
self until  the  examination  had  been  in  progress 
for  4 to  5 hours.  Therefore,  it  was  impossible 
for  him  to  stand  examination  in  such  a limited 
time  and  he  was  told  that  his  temporary  certifi- 
cate had  expired  and  it  would  be  a violation  of 
law  to  continue  practicing  until  he  obtained  an- 
other certificate.  Therefore,  he  was  denied  prac- 
ticing in  Louisiana  by  the  United  States  Court. 
This  injunction  was  issued  very  quickly,  the  day 
before  the  Federal  Judge  left  for  summer  vaca- 
tion. Subsequently,  in  November,  Dr  Prosser 
was  fined  for  Contempt  of  Court  for  disregard- 


ing the  injunction  which  had  been  issued  in  the 
summer.  Dr  Prosser  came  before  the  Board  but 
did  not  obtain  a certificate  and  then  a few  days 
afterward  he  obtained  a mandamus  to  try  and 
force  the  Board  to  issue  him  a certificate  to  prac- 
tice, claiming  that  the  Board  was  biased  and 
prejudiced  against  him  because  he  advertised 
in  the  Daily  Press!  When  these  proceedings  went 
to  trial,  they  were  continued  indefinitely  because 
of  the  illness  of  the  Judge.  However,  the  follow- 
ing letter  was  received  from  the  Attorney  of  the 
Board  which  stated,  "Dear  Sir:  I have  the  honor 
to  inform  you  that  Dr  S S Prosser  has  left  the 
city  in  consequence  of  the  proceedings  taken  up 
by  your  Board  against  him.  He  has  abandoned 
his  suit  in  the  State  Court,  the  proceedings  of 
the  United  States  Court  will  hereafter  be  merely 
informal  so  as  to  make  perpetual  the  injunction 
already  issued."  The  advertisements  that  fol- 
lowed of  the  "ABBO"  Medical  Institute  stated 
that  Dr  Brisbane,  who  was  a practicing  physi- 
cian in  the  State,  was  now  the  Director  of  the 
Institute  and  that  Dr  Prosser  had  left  town.  The 
editorial  comment  continues,  stating  that  "the 
Board  successfully  ousted  soi-diasant  'ABBO' 
and  has  prevented  Prosser  from  practicing  in  the 
State  of  Louisiana.  The  Journal  has  from  time  to 
time  reflected  upon  the  Board  and  feels  now  that 
credit  is  due  and  should  be  given  for  the  suc- 
cessful issue  of  the  legal  proceedings  in  the  case. 
It  yet  remains  for  the  Board  to  bury  the  name  of 
'ABBO'  by  instituting  the  necessary  measures 
to  stop  his  successor  from  practicing  under  the 
same  false  title." 

There  is  a case  by  Dr  Orville  Hurwitz  of  the 
treatment  of  cases  of  psychic  impotence.  He  has 
two  cases  of  sexual  impotence  in  which  he  states 
a 33-year-old  patient  had  an  attack  of  anterior 
urethritis  which  ran  the  usual  course  and  gave 
him  no  special  trouble.  However,  as  he  stated, 
there  was  complete  abeyance  of  his  "sexual 
power".  He  became  greatly  depressed,  he  had 
pains  in  parts  of  the  body  and  suffered  episodes 
of  dyspepsia  and  nervous  alopecia.  Examination 
showed  no  pathological  condition  except  a slight 
hyperesthesia  in  the  posterior  urethra.  He  had 
been  under  treatment  for  several  months  and 


60  J La  State  Med  Soc  VOL  1 52  February  2000 


nearly  recovered  the  use  of  his  lost  powers.  He 
goes  on  to  formulate  that  here  was  a case  of  im- 
potency  without  cause  and  an  illustration  of  pure 
psychic  impotence.  The  main  point  of  treatment 
was  to  produce  a mental  impression  upon  the 
patient.  He  goes  on  to  state  that  "under  no  cir- 
cumstances are  you,  the  physician,  to  let  him 
think  that  the  cause  of  his  trouble  is  mental.  Some 
simple  medicine  should  be  given  to  the  patient 
such  as  placebos.  They  should  be  given  for  the 
mental  effect  and  not  for  its  clinical  use.  One 
must  listen  with  interest  and  attention  to  the 
man's  story  and  gain  his  confidence  which  is  the 
greatest  aid  in  handling  these  cases.  The  pass- 
ing of  a cold  bougie  or  sound  will  produce  an 
impression  on  the  mind  and  may  be  a slight 
stimulation  of  the  nerves  though  in  itself  it's  re- 
ally of  no  use.  The  physical  condition  of  the  pa- 
tient should  be  improved  as  much  as  possible 
by  careful  psychological  guidance."  However, 
he  goes  on  to  state,  "a  great  mental  impression 
is  made  by  the  use  of  electricity,  if  applied  in 
cases  of  atonic  impotency  from  early  'sexual  ex- 
cess'. One  electrode  is  carried  into  the  rectum, 
the  bone  resting  against  the  prostate,  the  other 
one  is  applied  against  the  perineum  by  means 
of  a sponge.  The  current  is  then  passed  from  the 
rectum  towards  the  perineum.  Two  or  three  mil- 
liamperes  should  be  used,  but,  if  a current  indi- 


cator is  not  used,  the  current  should  be  strong 
enough  to  produce  a tingling  sensation  but  not 
shock.  This  situation  should  be  applied  daily  for 
5 minutes  at  a time  and  then  gradually  increased 
to  10.  This  treatment  will  be  found  of  service  in 
the  class  of  cases  mentioned  as  well  as  in  an 
atonic  condition  resulting  from  other  causes. 
This,  as  well  as  psychological  support,  helps 
these  patients  get  over  their  cases  of  psychic 
impotence." 


Dr  Colon  has  a plastic  surgery  practice  in 
Metairie,  Louisiana  and  has  lectured  on  history  of  medicine 
at  Louisiana  State  University  Health  Services  Center  and 
Tulane  University  School  of  Medicine, 
both  in  New  Orleans,  Louisiana. 


J La  State  Med  Soc  VOL  152  February  2000  01 


National  Leadership  Development  Conference 


Save  the  date! 

March  25-28,  2000 


Fontainebleau  Hilton  Hotel 
4441  Collins  Avenue 
Miami  Beach,  Florida  33140 


Is  it  good  medicine? 

A call  to  lead:  A challenge  to  serve 


Make  plans  now  to  join  virtually  every  leader  in 
organized  medicine  today  in  sunny  Miami  Beach 

for  the  2000  National  Leadership 
Development  Conference. 

Plenary  sessions  will  feature  nationally  acclaimed 
speakers  and  panel  participants. 

Tom  Peters,  PhD,  acclaimed  author  of  In  Search 
of  Excellence  and  The  Circle  of  Innovation,  is  the 
keynote  speaker. 

Ian  Morrison,  PhD,  Senior  Fellow,  Institute  for 
the  Future,  and  noted  author  and  consultant,  will 
address  Healthcare  in  the  New  Millennium. 

Interactive  break-out  and  optional  sessions  will 
include  opportunities  such  as  the  AM. A /Intel 
Internet  Health  Road  Show  and: 

• Future  role  of  medical  associations 

• Breakfast  and  luncheon  dialogues  with  your 
AMA  leadership 

• How  to  write  a speech 

• Media  interview  skills  update 

• Regaining  physician  collegiality  in  the  medical 
profession 

• Medical  practice  management 

• Association  management  and  team  building 

• Leadership  skill  building 


To  register  for  the  NLDC  and  for  additional 
information: 

Call  the  AMA  registration  hotline,  800  262-3211 
or  visit  the  NLDC  Web  site,  www.ama-assn.org 

To  reserve  a hotel  room: 

Call  800  548-8886  or  305  538-2000  or  visit  the 
hotel  Web  site,  www.hilton.com 

To  receive  special  room  rates,  be  sure  to: 

Identify  yourself  as  a participant  in  the  2000 
National  Leadership  Development  Conference. 
Register  before  the  February  25,  2000,  cut-off  date. 

AMA/ Glaxo  Wellcome 

Emerging  Leaders  Development  Program 

This  day-long  skill-building  experience  on  March  25, 

2000,  is  by  invitation  only  and  is  limited  to  50  physicians. 
The  program  aims  to  help  physicians  succeed  in  the 
legislative /regulatory,  organized  medicine,  and  managed 
care  arenas.  An  application,  which  must  be  postmarked  by 
December  17,  1999,  can  be  found  on  the  AMA  Web  site 
at  www.ama-assn.org.  Participation  includes  complimen- 
tary registration  for  the  NLDC  and  CME  credit. 

American  Medical  Association 

Physicians  dedicated  to  the  health  of  America 


Public  Health 


Public  Health  in  Louisiana: 
An  Introduction 


Elizabeth  T.H.  Fontham,  DrPH 


We  are  pleased  to  welcome  you  to  this 
special  public  health  issue  of  The 
Journal  of  the  Louisiana  State  Medi- 
cal Society,  the  result  of  a collaborative  project 
with  Louisiana  State  University  Health  Sci- 
ences Center,  Louisiana  Public  Health  Asso- 
ciation, and  the  Louisiana  State  Medical  Soci- 
ety. Focusing  on  important  health  topics  which 
link  medicine  and  public  health  in  Louisiana, 
this  issue  features  articles  addressing  rural 
health,  the  state  health  code,  ingested  lead  lev- 
els, and  public  health  projects  throughout  the 
State.  Physicians  who  are  interested  in  expand- 
ing their  public  health  knowledge  can  read 
about  the  variety  of  educational  opportunities 
available  to  them  throughout  the  State,  includ- 
ing some  innovative  distance  learning  pro- 
grams. 

This  project  has  been  supported  through 
the  Cooperative  Actions  for  Health  Program 
(CAHP),  a collaborative  grant  co-sponsored  by 
the  American  Public  Health  Association  and 
the  American  Medical  Association,  with  fund- 
ing from  The  Robert  Wood  Johnson  Founda- 
tion. We  believe  that  collaboration  between 
medicine  and  public  health  is  essential  for 
improving  the  health  of  the  people  we  serve. 


We  congratulate  the  leaders  of  the  Loui- 
siana CAHP  project,  Drs  Larry  Hebert  and 
James  Osterberger,  co-chairmen  of  the 
project,  and  Dr  Anne  Jordan,  who  has  served 
as  the  Project  Coordinator.  We  hope  that  their 
efforts,  and  the  work  of  the  authors  who 
have  contributed  to  this  special  issue,  inspire 
new  and  expanded  partnerships  between 
medicine  and  public  health  in  service  to  the 
people  of  Louisiana. 


Dr  Fontham  is  Professor  and  Chairman  of  the 
Department  of  Public  Health  and  Preventive  Medicine , 
LSU  Health  Sciences  Center  in  New  Orleans , Louisiana 


J La  State  Med  Soc  VOL  152  February  2000  S3 


Public  Health 


Blood  Mercury  Levels  and 
Fish  Consumption  in  Louisiana 

Tracie  M.  Bellanger,  BA;  Erica  M.  Caesar,  MSPH; 
Louis  Trachtman,  MD,  MPH 


The  primary  source  of  non-occupational  exposure  to  mercury  is  through  the  consumption  of 
contaminated  fish.  Since  1994,  the  Louisiana  Department  of  Environmental  Quality  has 
reported  mercury  contamination  in  fish  obtained  from  bodies  of  water  throughout  the  state 
and  has  issued  fish  consumption  advisories  accordingly.  To  determine  the  extent  of  mercury 
intoxication  in  Louisiana,  screening  for  blood  mercury  levels  was  offered  to  volunteers 
residing  near  selected  advisory  areas.  A total  of  313  residents  participated  in  the  screening;  6 
were  found  to  have  elevated  levels.  No  level  was  detected  in  48  of  the  participants,  while  the 
remaining  participants  had  normal  levels.  Significantly  higher  levels  were  found  in  those 
associated  with  commercial  fishing  and  those  reporting  increased  fish  consumption.  For 
most  people,  ordinary  consumption  of  fish  contaminated  with  mercury  does  not  currently 
appear  to  pose  a public  health  hazard  in  Louisiana;  however,  educational  efforts  regarding 
the  risks  of  fish  consumption  in  great  quantities  should  be  continued. 


Whether  from  natural  sources  such  as 
mineral  deposits,  oceanic  emissions, 
and  volcanic  eruptions,  or  from  hu- 
man activities  such  as  mining,  combustion  of 
fossil  fuels,  and  industrial  emissions,  mercury 
is  a substance  present  everywhere  in  the  envi- 
ronment. Methyl  mercury,  the  most  common 
organic  form  of  mercury,  is  produced  when  mi- 
croorganisms in  the  soil  and  water  interact  with 
inorganic  mercury.  Because  it  has  a high  affin- 
ity for  protein  sulfhydryl  groups,1  methyl  mer- 
cury accumulates  in  organisms  and  is  enriched 
along  the  food  chain.2 

64  J La  State  Med  Soc  VOL  152  February  2000 


While  terrestrial  food  is  a negligible  source 
of  methyl  mercury  for  the  general  population, 
certain  aquatic  species,  particularly  large  preda- 
tory fish,  accumulate  this  organic  form  of  mer- 
cury in  liver,  kidney,  brain,  and  muscle  tissues.3 
Thus,  the  primary  source  of  non-occupational 
exposure  to  mercury  for  humans  is  through  the 
consumption  of  contaminated  fish.4 

The  potential  for  mercury  toxicity  in  Louisi- 
ana residents  is  a legitimate  concern  for  two  rea- 
sons. First  of  all,  fish  is  a main  dietary  compo- 
nent in  this  state  and  much  of  the  fish  consumed 
is  caught  in  local  waters.  Secondly,  the  Louisi- 


Public  Health 


ana  Department  of  Environmental  Quality  has 
reported  the  presence  of  mercury  in  fish  ob- 
tained from  local  bodies  of  water.  Since  1994,  this 
department  has  conducted  annual  testing  in 
more  than  100  bodies  of  water  throughout  the 
state.  The  edible  portions  of  the  fish  tested  were 
found  to  have  mercury  contamination  in  all 
tested  areas.  Advisories  regarding  the  consump- 
tion of  mercury  contaminated  fish  have  been  is- 
sued by  the  Louisiana  Department  of  Health  and 
Hospitals,  the  Louisiana  Department  of  Environ- 
mental Quality,  and  the  Louisiana  Department 
of  Wildlife  and  Fisheries  (Appendix). 

Louisiana  is  not  facing  this  problem  alone. 
In  1992,  the  state  of  Arkansas  began  creating 
similar  advisories  after  discovering  mercury  lev- 
els in  local  fish  exceeded  the  Food  and  Drug  Ad- 
ministration (FDA)  tolerance  limits.5  To  deter- 
mine the  extent  of  mercury  intoxication,  the  Ar- 
kansas Department  of  Health  provided  baseline 
blood  mercury  screening  to  volunteers  who 
lived  in  eight  affected  counties.  Two  hundred 
thirty-six  participants,  who  confirmed  their  fish 
consumption  was  a minimum  of  two  meals  per 
month  of  fish  caught  in  the  lower  Saline  or 
Ouachita  Rivers,  were  tested.  Fifteen  percent  of 
those  tested  were  found  to  have  blood  mercury 
levels  in  the  elevated  range  of  20-75  parts  per 
billion  (ppb),  while  25%  were  found  to  have  no 
detectable  blood  mercury  levels.6 

Increasing  public  awareness  of  the  presence 
of  mercury  in  our  environment  and  the  poten- 
tial for  toxicity  has  prompted  the  Louisiana  state 
legislature  to  follow  in  Arkansas'  footsteps  and 
provide  similar  screening  for  elevated  blood 
mercury  levels  in  residents  living  near  selected 
advisory  areas.  This  screening  is  essential  to 
determine  the  extent  of  mercury  intoxication  in 
Louisiana  residents  and  to  evaluate  the  poten- 
tial health  risks  of  consuming  contaminated  fish 
caught  in  local  waters. 

I n this  article,  we  review  the  historical  and 
toxicological  considerations  of  mercury  poison- 
ing and  discuss  the  results  of  this  screening  with 
regard  to  age,  occupation,  race,  education,  fre- 
quency of  fish  consumption,  and  pregnancy. 


Historical  Considerations 

Mercury  was  first  used  medically  to  treat 
syphilis  in  the  late  15th  century.7  Gradually,  its 
toxicity  became  known  and  by  the  19th  century 
it  was  generally  accepted  as  toxic  and  its  me- 
dicinal use  was  markedly  decreased.  The  toxic- 
ity of  mercury  was  brought  to  the  attention  of 
the  scientific  community  by  its  use  in  industry. 
In  1863,  Frankland  and  Duppa  used  dimethyl 
mercury  to  determine  the  valency  of  metals  and 
metallic  compounds.8  Later  that  year,  two  labo- 
ratory technicians  participating  in  the  study  died 
of  mercury  intoxication.9  Consequently, 
mercury's  toxicity  became  well  known  among 
chemists;  however,  physicians  did  not  appreci- 
ate the  potential  for  mercury  intoxication  until 
an  industrial  accident  brought  it  to  the  forefront. 
In  1940,  four  industrial  workers  were  hospital- 
ized with  methyl  mercury  poisoning  as  a result 
of  an  industrial  accident.10  In  1950,  one  of  those 
workers  died;  the  subsequent  autopsy  revealed 
destruction  of  neurons  with  cerebral  and  cerebel- 
lar atrophy.  These  pathological  findings  along 
with  the  presenting  symptoms  of  progressive 
ataxia,  impaired  speech,  and  constricted  visual 
field  became  known  as  Hunter-Russell  syn- 
drome and  methyl  mercury  was  designated  the 
etiologic  agent.11 

Meanwhile,  in  the  early  1950s,  the  Chisso 
Corporation  chemical  factory  was  discharging 
its  waste  effluent,  contaminated  with  methyl 
mercury,  into  Minamata  Bay  in  Japan — a com- 
mon practice  at  the  time.  A disease  similar  to 
Hunter-Russell  syndrome  emerged,  but  it  also 
presented  with  deafness  and  sensory  abnormali- 
ties. Minamata  Disease,  as  it  was  named,  was 
not  officially  recognized  by  the  Japanese  gov- 
ernment as  being  caused  by  environmental  pol- 
lution with  methyl  mercury  until  1968. 12  More 
than  2,250  patients  have  been  officially  recog- 
nized as  having  Minamata  Disease,  1,043  of 
whom  have  died.13  The  number  of  unofficial 
sufferers  is  believed  to  be  much  greater. 

A second  epidemic  of  mercury  poisoning 
occurred  in  1976  in  Iraq.  More  than  6,000  people 


J La  State  Med  Soc  VOL  1 52  February  2000  65 


Public  Health 


were  affected  when  they  consumed  bread  made 
from  grain  treated  with  methyl  mercury  fungi- 
cide. At  least  500  of  those  people  died  as  a result 
of  the  intoxication.14  Similar  episodes  have  oc- 
curred with  seed  grain  contaminated  with  me- 
thyl mercury  in  Guatemala15  and  Pakistan.16 

Several  regulations  have  been  established 
regarding  methyl  mercury  since  these  outbreaks 
have  occurred.  In  1973,  an  allowable  mercury 
concentration  in  fish  was  established  by  Japan's 
Ministry  of  Health  and  Welfare — total  mercury 
at  0.4  gg/g  and  methyl  mercury  at  0.3  gg/g.17 
Government  authorities  also  established  that 
there  should  be  no  detectable  mercury  or  me- 
thyl mercury  in  industrial  waste  water. 

In  the  United  States,  the  FDA  established  an 
action  level  of  1 ppm  methyl  mercury;  commer- 
cial fish  and  shellfish,  as  well  as  treated  seed 
grain,  sold  through  interstate  commerce  found 
to  have  levels  exceeding  1 ppm  cannot  be  sold 
to  the  public.  The  Environmental  Protection 
Agency  (EPA),  in  conjunction  with  the  FDA,  has 
set  a limit  of  2 ppb  inorganic  mercury  in  drink- 
ing water.  The  EPA  also  currently  recommends 
the  level  of  inorganic  mercury  in  rivers,  lakes, 
and  streams  should  be  less  than  144  parts  per 
trillion  (ppt)  to  protect  human  health.18 

Toxicological  Considerations 

The  critical  organ  system  affected  in  humans 
by  methyl  mercury  is  the  central  nervous  sys- 
tem. Mercury  is  a neurotoxic  agent,  affecting  pri- 
marily the  occipital  cortex  and  cerebellum.19  Me- 
thyl mercury  poisoning  is  evident  with  low  lev- 
els of  exposure  and  presents  most  commonly 
with  nonspecific  signs  and  symptoms,  includ- 
ing paresthesias,  ataxia,  constriction  of  the  vi- 
sual field,  and  impairment  of  hearing.20  With 
prolonged  daily  methyl  mercury  intake  of  3-7 
gg/kg  body  weight,  the  incidence  of  poisoning 
is  5%. 21 

Prenatal  exposure  to  high-dose  methyl  mer- 
cury is  particularly  devastating  and  can  cause 
mental  retardation  and  cerebral  palsy  in  the  new- 
born. In  all  cases  of  reported  fetal  methyl  mer- 
cury poisoning,  the  source  was  dietary;  however. 


only  in  Minamata  and  Niigata,  Japan,  was  fish 
consumption  involved.22  The  fish  consumed  in 
these  areas  contained  very  high  methyl  mercury 
levels  secondary  to  local  waterway  pollution. 
Consumption  of  fish  with  low  levels  of  methyl 
mercury,  below  1 ppm,  during  pregnancy  has 
not  been  shown  to  place  the  fetus  at 
neurodevelopmental  risk.23 

The  International  Commission  of  Occupa- 
tional Health  and  the  International  Union  of  Pure 
and  Applied  Chemistry  Commission  on  Toxi- 
cology have  determined  the  average  baseline 
whole  blood  level  of  mercury  to  be  approxi- 
mately 2 ppb  in  people  who  do  not  eat  fish.24  In 
people  who  do  eat  fish,  a normal  blood  level  of 
mercury  is  between  2 and  20  ppb.  Levels  greater 
than  20  ppb  are  considered  elevated  and  it  is 
recommended  that  those  people  decrease  fish 
consumption.  Levels  greater  than  80  ppb  in  the 
general  population25  and  40  ppb  in  children  and 
pregnant  women26  need  medical  evaluation,  as 
well  as  decreased  consumption  of  fish.  Levels 
greater  than  200  ppb  are  associated  with  a 5% 
incidence  of  poisoning.27  This  level  results  from 
chronic  daily  methyl  mercury  intake  of  3-4  gg/ 
kg  body  weight  for  at  least  1 year.28 

Screening  Protocol 

From  February  to  March  of  1998,  the  State 
Office  of  Public  Health  offered  free  blood  mer- 
cury screening  through  local  parish  health  units 
to  residents  in  thirteen  parishes,  including 
Acadia,  Caldwell,  Evangeline,  Iberia,  Jefferson 
Davis,  Lafayette,  Morehouse,  Ouachita,  St 
Landry,  St  Martin,  St  Tammany,  Vermilion,  and 
Washington  parishes.  Participants  also  com- 
pleted a written  questionnaire  regarding  risk 
factors  for  mercury  poisoning. 

Whole  blood  samples,  collected  by  venipunc- 
ture, were  analyzed  by  cold  vapor  atomic  ab- 
sorption in  the  Office  of  Public  Health  Central 
Laboratory,  New  Orleans,  Chemistry  Section. 
This  laboratory  complies  with  the  quality  con- 
trol procedures  recommended  by  the  Center  for 
Disease  Control  and  Prevention  (CDC).  The  limit 
for  detection  of  blood  mercury  is  0.30  ppb. 


66  J La  State  Med  Soc  VOL  152  February  2000 


Public  Health 


Residents  believed  to  be  at  high  risk  were 
specifically  targeted  for  this  screening.  Women 
who  were  pregnant,  breastfeeding,  or  had  small 
children  were  informed  of  the  screening  through 
the  Women,  Infants,  and  Children  Supplemen- 
tal Food  Program  (WIC).  Commercial  fisherman 
and  charter  boat  captains  were  informed  of  the 
screening  service  by  mail. 

Screening  Results 

Three  hundred  thirteen  residents  partici- 
pated in  the  screening,  including  187  females 
and  126  males.  Racial  distribution  of  participants 
was  65.5%  white,  29.7%  black,  and  4.8%  who 
consider  themselves  a different  race  or  ethnicity. 
Educational  level  of  the  participants  varied  as 
follows:  34.2%  did  not  graduate  from  high 
school,  30.1%  graduated  from  high  school  or 
received  a General  Equivalency  Diploma,  and 
29.7%  pursued  education  beyond  high  school. 
A description  of  the  participants  by  annual  in- 
come is  as  follows:  27%  earned  <$10,000,  21.4% 
earned  $10,000-$19,000,  25.6%  earned  $20,000- 
$50,000,  10.2%  earned  >$50,000,  and  15.3%  re- 
fused to  disclose  income.  Table  1 (shown  on  next 
page)  displays  a summary  of  the  participants  in 
regard  to  parish  population. 

Of  the  313  people  screened,  6 (1.9%)  had  el- 
evated blood  mercury  levels  of  20  ppb  or  more. 
In  those  with  elevated  levels,  no  relationship  was 
observed  regarding  the  species  of  fish  con- 
sumed; although,  each  of  these  people  con- 
sumed blue  catfish,  channel  catfish,  largemouth 
bass,  or  white  crappie.  Those  with  elevated  lev- 
els were  white  commercial  fishermen  or  family 
members  of  fishermen  who  resided  in 
Morehouse  or  Ouachita  parishes.  Table  2 depicts 
the  screening  results  for  these  six  individuals. 

In  48  (15.3%)  of  the  participants,  no  blood 
mercury  level  was  detected.  The  remainder  of 
participants  had  normal  levels  in  the  range  0.5- 
19.9  ppb. 

The  data  were  analyzed  in  regard  to  age, 
occupation,  race,  education,  frequency  of  fish 
consumption,  and  pregnancy.29  Means  and 
medians  were  calculated  for  each  group  and  a 


sign  test  (P  = 0.05)  was  performed  to  test  for  sig- 
nificant differences. 

Five  age  categories  were  created — <7  years 
(n  = 22),  7-19  years  (n  = 32),  20-39  years  (n  = 89), 
40-59  years  (n  = 75),  and  >60  years  (n  = 93).  Par- 
ticipants <7  years  old  had  a significantly  lower 
mean  blood  mercury  concentration  of  2.15  ppb 
as  compared  to  all  age  groups  as  a whole.  Those 
ages  7-19  had  a significantly  lower  mean  blood 
mercury  concentration  of  1.39  ppb  as  compared 
to  all  screening  participants  as  a whole.  The 
mean  levels  for  the  remaining  age  groups  are  as 
follows:  age  20-39  = 2.63  ppb,  age  40-59  = 4.45 
ppb,  and  age  >60  = 4.30  ppb.  Although  the  lev- 
els for  these  three  age  groups  were  not  found  to 
be  significantly  different,  there  is  a trend  for 
blood  mercury  levels  to  increase  with  increas- 
ing age. 

Occupation  was  related  to  higher  blood  mer- 
cury levels.  Commercial  fishermen  and  their 
household  members  (n  = 18)  had  significantly 
higher  levels  than  those  in  other  occupations, 
with  a mean  of  6.65  ppb  as  compared  to  3.21 
ppb  in  all  others  tested  (n  = 295). 

Mean  blood  mercury  levels  for  black  study 
participants  (n  = 93)  was  2.43  ppb.  This  level  is 
significantly  lower  than  the  mean  of  3.84  ppb 
for  the  white  participants  (n  = 205).  Also,  other 
racial /ethnic  groups  (n  = 15)  had  significantly 
lower  levels,  mean  of  3.67  ppb,  as  compared  to 
whites. 

In  participants  who  did  not  graduate  high 
school  (n  = 107),  the  mean  blood  mercury  level 
is  3.67  ppb;  high  school  graduates  and  GED 
holders  (n  = 93)  had  mean  levels  of  3.43  ppb; 
those  with  higher  education  (n  = 97)  had  mean 
levels  of  2.96  ppb.  There  is  a trend  for  levels  to 
decrease  as  education  increases;  however,  none 
of  the  mean  or  median  blood  mercury  levels 
were  significantly  different  in  regard  to  educa- 
tion. 

Data  regarding  frequency  of  fish  consump- 
tion was  divided  into  three  categories:  at  least 
once  per  week,  once  or  twice  a month,  or  less 
than  six  times  a year.  Those  who  ate  fish  at  least 
once  per  week  (n  = 181)  had  a significantly 


J La  State  Med  Soc  VOL  152  February  2000  67 


Public  Health 


higher  blood  mercury  level,  mean  of  4.32  ppb, 
as  compared  to  the  other  two  groups.  Those 
who  ate  fish  once  or  twice  a month  (n  = 85)  had 
a mean  level  of  1.82  ppb  and  those  who  ate  fish 
less  than  six  times  a year  (n  = 26)  had  a mean 
level  of  2.08  ppb.  All  those  with  elevated  blood 
mercury  levels  in  this  screening  (n  = 6)  reported 
fish  consumption  of  at  least  once  a week. 

The  mean  blood  mercury  level  among  preg- 
nant women  (n  = 52)  was  2.03  ppb.  No  elevated 
levels  were  detected  in  this  group  of  partici- 
pants. There  was  no  statistically  significant  dif- 
ference in  levels  among  all  female  participants 
in  regards  to  pregnancy  status. 


DISCUSSION 

Mercury  occurs  naturally  in  the  environment  and 
everyone  is  exposed  to  low  levels  of  mercury 
through  the  air  we  breathe  and  the  food  and  wa- 
ter we  drink.  Human  activities,  such  as  mining, 
combustion  of  fossil  fuels,  chloroalkali  produc- 
tion, and  mineral  processing,  increase  the  levels 
of  mercury  we  are  exposed  to.  The  majority  of 
mercury  in  the  environment  is  inorganic  or  me- 
tallic mercury;  exposure  to  this  form  of  mercury 
is  usually  through  inhalation,  but  also  occurs 
through  dietary  and  dermal  pathways.  Inorganic 
mercury  vapors  are  released  from  metallic  mer- 


Table  1 . Summary  of  Participants  and  Parishes  Population  Data 

PARISH 

# OF  PARTICIPANTS 

PARISH  POPULATION* 

MALE 

FEMALE 

ACADIA 

3 

5 

56,855 

BRADLEY**  (ARKANSAS) 

1 

0 

Not  Available 

CALDWELL 

6 

15 

10,334 

EVANGELINE 

1 

2 

33,967 

JACKSON** 

0 

1 

15,683 

JEFFERSON  DAVIS 

1 

3 

31,380 

LA  SALLE** 

1 

1 

13,795 

LAFAYETTE 

1 

5 

176,592 

MOREHOUSE 

22 

70 

32,062 

ORLEANS 

1 

1 

484,194 

OUACHITA 

43 

48 

146,449 

ST.  LANDRY 

2 

1 

82,156 

ST.  MARTIN 

1 

0 

45,741 

ST.  TAMMANY 

19 

16 

167,242 

UNION** 

1 

4 

21,475 

VERMILION 

1 

0 

50,794 

WASHINGTON 

22 

15 

42,899 

TOTAL 

126 

187 

* Wessex,  Incorporated.  1994  Population  Estimates 

**  These  individuals  presented  at  the  clinic  and  were  tested.  Their  parish /county  of  residence  was  not 
targeted  in  this  screening. 

Note:  This  table  reproduced  with  permission  from  ATSDR,  Review  of  mercury  health  services'  blood  mercury 
data  for  selected  parishes  in  Louisiana,  Atlanta:  ATSDR;  1999. 

68  J La  State  Med  Soc  VOL  152  February  2000 


Public  Health 


Table  2.  Summary  of  Participants  with  Eievated  Blood  Mercury  Levels 

Gender 

PARISH  OF  RESIDENCE 

LEVEL  (PPB) 

Male 

Ouachita 

19.6* 

Male 

Morehouse 

20.6 

Female 

Ouachita 

22.9 

Male 

Ouachita 

26.7 

Male 

Morehouse 

30.7 

Male 

Ouachita 

35.1 

Mean:  25.93  ppb  Median:  24.8  ppb 

*This  level  was  included  in  the  elevated  range  because  of  its  close  proximity  to  the  cutoff  value  of  20  ppb 

Note:  This  table  reproduced  with  permission  from  ATSDR,  Review  of  mercury  health  services'  blood  mercury  data  for 

selected  parishes  in  Louisiana,  Atlanta:  ATSDR;1999. 

cury  spills,  incinerators,  and  amalgam  dental 
fillings.30  Methyl  mercury  is  an  organic  form  of 
mercury  created  when  microorganisms  in  the  en- 
vironment interact  with  inorganic  mercury.  Ex- 
posure to  organic  mercury  is  through  inhalation, 
dermal,  and  dietary  sources,  as  well.  Consump- 
tion of  fish  living  in  contaminated  waters  is  the 
primary  source  of  non-occupational  exposure  to 
methyl  mercury  for  humans. 

Analysis  of  the  screening  data  provides  new 
information  regarding  the  risk  of  methyl  mer- 
cury intoxication  for  Louisiana  state  residents. 
Most  importantly,  98%  of  those  screened  had 
blood  mercury  levels  in  the  normal  range  and 
none  of  those  screened  had  levels  in  the  toxic 
range.  Therefore,  ordinary  consumption  of  lo- 
cal fish  contaminated  with  methyl  mercury,  for 
most  people,  does  not  appear  to  pose  a public 
health  hazard  at  this  time. 

The  six  participants  in  the  study  with  el- 
evated blood  mercury  levels  were  all  commer- 
cial fishermen  or  family  members  and  lived  in 
two  of  the  thirteen  parishes  targeted — Ouachita 
and  Morehouse  parishes.  This  may  be  second- 
ary to  increased  consumption  of  locally  caught 
fish,  as  it  is  anecdotally  known  that  fishermen 
eat  more  fish  than  non-fishing  people  do.  In- 
creased frequency  of  fish  consumption  is  an  es- 
tablished risk  factor  for  elevated  blood  mercury 
levels.31  None  of  these  participants  had  levels 


high  enough  to  require  medical  evaluation;  how- 
ever, it  is  important  to  continue  educational  ef- 
forts to  all  fishermen  throughout  the  state  regard- 
ing the  risks  of  fish  consumption  in  great  quan- 
tities. 

There  are  several  possible  explanations  as  to 
why  participants  with  elevated  levels  were  resi- 
dents of  only  Ouachita  and  Morehouse  parishes. 
Perhaps  the  fish  from  the  bodies  of  water  in  these 
parishes  have  greater  levels  of  methyl  mercury 
contamination;  thus,  residents  of  these  parishes 
who  are  more  likely  to  consume  locally  caught 
fish  would  be  more  likely  to  have  elevated  blood 
mercury  levels.  It  is  also  possible  that  increased 
numbers  of  volunteers  from  these  two  parishes 
have  skewed  the  data — 29%  of  participants  were 
from  Morehouse  parish  and  29%  were  from 
Ouachita  parish.  Further  study  is  necessary  to 
evaluate  the  true  relationship  between  residing 
in  these  two  parishes  and  risk  for  elevated  blood 
mercury  levels. 

In  this  screening,  blood  mercury  levels  in- 
creased with  increasing  age.  This  is  in  agreement 
with  other  studies,  which  have  considered  age 
as  a factor  in  methyl  mercury  exposure.32  This 
may  be  due  to  increased  fish  consumption  with 
increasing  age.  People  45  years  and  older  have 
been  shown  to  have  higher  fish  consumption 
and  mercury  exposure  than  people  in  the  15-44 
year  age  group.33  Presumably,  there  is  accumu- 


J La  State  Med  Soc  VOL  152  February  2000  69 


Public  Health 


lation  of  methyl  mercury  within  the  body, 
which  explains  increasing  levels  with  increas- 
ing age.  Methyl  mercury  is  excreted  primarily 
through  the  biliary-hepatic  cycle;  this  contrib- 
utes to  the  long  clearance  half-life,  estimated 
at  approximately  50  days.34  Individuals  who 
consume  fish  on  a frequent  basis  are  accumu- 
lating methyl  mercury  in  the  body  faster  than 
it  can  be  excreted. 

In  considering  the  results  of  this  screening, 
we  must  point  out  some  limiting  factors.  First, 
these  results  may  or  may  not  apply  to  the  gen- 
eral public  as  a whole.  Participants  were  self- 
selected  volunteers  and  not  chosen  by  random 
methods.  Also,  the  voluntary  nature  of  the 
study  limited  the  number  of  participants;  fu- 
ture studies  with  a larger  number  of  partici- 
pants might  suggest  different  conclusions.  Fi- 
nally, recall  error  may  be  an  issue  in  regards  to 
the  accuracy  of  the  written  questionnaires  par- 
ticipants completed  concerning  risk  factors  for 
methyl  mercury  exposure. 

Despite  the  limitations  of  applying  this 
screening  data  to  the  general  population,  rec- 
ommendations can  be  made  regarding  preven- 
tion of  methyl  mercury  intoxication  in  Louisi- 
ana State  residents.  Primarily,  the  state  should 
continue  annual  testing  of  waterways  for  con- 
tamination with  mercury  and  advisories  re- 
garding fish  consumption  should  be  updated 
accordingly.  Also,  educational  efforts  regard- 
ing the  risk  of  methyl  mercury  exposure 
through  increased  consumption  of  locally 
caught  fish  should  continue.  These  efforts 
should  be  directed  towards  members  of  high- 
risk  groups,  such  as  commercial  and  sports 
fishermen  and  their  families.  Fortunately,  none 
of  those  screened  had  blood  mercury  levels 
high  enough  to  warrant  medical  evaluation. 
For  this  to  remain  true,  the  state  must  remain 
vigilant  and  continue  annual  monitoring  of 
waterways  for  contamination  in  an  attempt  to 
prevent  methyl  mercury  poisoning  from  the 
consumption  of  locally  caught  fish. 


ACKNOWLEDGMENTS 

We  gratefully  acknowledge  the  United  States 
Agency  for  Toxic  Substances  and  Disease  Regis- 
try (ATSDR  program  607)  and  the  Louisiana  De- 
partment of  Environmental  Quality,  which 
helped  fund  this  study.  We  would  also  like  to 
thank  several  people  who  contributed  to  the  ini- 
tial data  analysis,  including  Kabrina  Smith,  MS; 
Margaret  Metcalf,  ScD.;  LuAnn  White,  PhD, 
DABT;  Elizabeth  T H Fontham,  DrPH;  Dianne 
Dugas,  MSW,  MPH;  William  Hartley,  ScD;  Barry 
Kohl,  PhD;  Frank  Welch,  MD,  MSPH;  Barbara 
Cooper,  MSPH;  George  Pettigrew,  ATSDR  Re- 
gional Representative;  William  Greim,  Division 
of  Health  Assessment  and  Consultation;  and 
Deborah  Millette,  ATSDR  Division  of  Health 
Studies. 

REFERENCES 

1.  Fergusson  JE.  The  Heavy  Elements:  Chemistry,  Envi- 
ronmental Impact,  and  Health  Effects.  Oxford: 
Pergamon;1990. 

2.  D'ltri  FM.  Mercury  contamination:  What  we  have 
learned  since  Minamata.  Environ  Monitor  Assess 
1991;19:165-182. 

3.  Renzoni  A,  Zino  F,  Franchi  E.  Mercury  levels  along 
the  food  chain  and  risk  for  exposed  populations. 
Environ  Res  1998;77:68-72. 

4.  Agency  for  Toxic  Substances  and  Disease  Registry 
(ATSDR).  Toxicological  Profile  for  Mercury.  Atlanta: 
ATSDR;  1997. 

5.  Armstrong  M,  Burge  P,  Evans  S,  et  al.  Mercury  in  Ar- 
kansas: 1993-1994  Biennium  Report.  June  1995;  Ch  2. 

6.  Burge  P,  Evans  S.  Mercury  contamination  in  Arkansas 
gamefish:  a public  health  perspective.  / Ark  Med  Soc 
1994;90:542-544. 

7.  O'Shea  JG.  Two  minutes  with  Venus,  two  years  with 
mercury:  mercury  as  an  antisyphilitic  chemotherapeu- 
tic agent.  J R Soc  Med  1990;83:392-395. 

8.  Frankland  E,  Duppa  BF.  On  a new  method  of  produc- 
ing the  mercury  compounds  of  the  alcohol-radicles.  J 
Chem  Soc  London  1863;16:415-425. 

9.  Edwards  GN.  Two  cases  of  mercuric  poisoning  by  mer- 
curic methide.  St  Barth  Hosp  Report  London  1865;1:141- 
150. 

10.  Hunter  D,  Bomford  RR,  Russell  DS.  Poisoning  by 
methy  1 mercury  compounds.  Q J Med  1940;9:193-213. 


70  J La  State  Med  Soc  VOL  152  February  2000 


Public  Health 


11.  Hunter  D,  Russell  DS.  Focal  cerebral  and  cerebellar 
atrophy  in  a human  subject  due  to  organic  mercury 
compounds.  / Neurol  Neurosurg  Psychiatry;  1954;17:235- 
241. 

12.  Powell  P.  Minamata  disease:  a story  of  mercury's  ma- 
levolence. South  Med  J 1991;84:1352-1358. 

13.  Harada  M.  Minamata  disease:  methylmercury  poison- 
ing in  Japan  caused  by  environmental  pollution.  Crit 
Rev  Toxicol  1995;25:1-24. 

14.  Bakir  F,  Damluji  SF,  Amin-Zaki  L,  et  al.  Methylmer- 
cury poisoning  in  Iraq:  an  inter-university  report.  Sci- 
ence 1973;181:230-241. 

15.  Ordonez  JV.  Estudios  epidemiologicos  de  una 
enfermedad  considerada  como  encefalitis  en  la  region 
de  los  altos  de  Guatemala.  Bol  Sanit  Panam 
1966;60:510-519. 

16.  Haq  IU.  Agrosan  poisoning  in  man.  BMJ  1963;1:1579- 
1582. 

17.  Tsubaki  T,  Irukayama  K (editors).  Minamata  Disease: 
Methyl  Mercury  Poisoning  in  Minamta  and  Niigata,  Ja- 
pan. Tokyo:  Kodansha  Ltd;  1977. 

18.  ATSDR.  Toxicological  profile  for  mercury  (update).  At- 
lanta: ATSDR;  1999. 

19.  Takeuchi  T.  Pathology  of  Minamata  Disease.  In: 
Minamata  Disease.  Japan:  Kumamoto  Univ;  1968:141- 
228. 

20.  World  Health  Organization  (WHO).  Mercury:  Environ- 
mental Health  Criteria  1.  Geneva:  WHO;  1976. 

21.  Nordberg  GF,  Strangert  P.  Fundamental  aspects  of 
dose-response  relationships  and  their  extrapolation  for 
non-carcinogenic  effects  of  metals.  Environ  Health 
Perspect  1978;22:97-108. 

22.  Harada  Y.  Congenital  Minamata  Disease.  In:  Minamata 
Disease.  Japan:  Kumamoto  Univ.;  1968:93-117. 

23.  Myers  GJ,  Davidson  PW.  Prenatal  methyl  mercury  ex- 
posure and  children:  neurologic,  developmental,  and 
behavioral  research.  Environ  Health  Perspect 
1998;106(suppl  3):841-847. 

24.  ATSDR.  Toxicological  profile  for  mercury.  Atlanta: 
ATSDR;  1997. 

25.  Ellenhorn  MJ.  Ellenhorn's  Medical  Toxicology:  Diagnosis 
and  Treatment  of  Human  Poisoning.  Baltimore:  Williams 
& Wilkens;  1997. 

26.  WHO.  Environmental  Health  Criteria  101:  Methyl  Mer- 
cury. Geneva:  WHO;  1990. 

27.  Galli  CL,  Restani  P.  Can  methyl  mercury  present  in 
fish  affect  human  health?  Pharmacol  Res  1993;27:115- 
127. 

28.  WHO.  Methyl  Mercury.  In:  Toxicological  Evaluation  of 
Certain  Food  Additives  and  Contaminants.  Cambridge: 
WHO;  1990:295-328. 

29.  ATSDR.  Health  Consultation:  Review  of  Mercury  Health 
Services' Blood  Mercury  Data  for  Selected  Parishes  in  Loui- 
siana. Atlanta:  ATSDR;  1999. 

30.  ATSDR.  Toxicological  profile  for  mercury  (update).  At- 
lanta: ATSDR;  1999. 


31.  Mahaffey  KR,  Mergler  D.  Blood  levels  of  total  and  or- 
ganic mercury  in  residents  of  the  upper  St  Lawrence 
River  Basin,  Quebec:  association  with  age,  gender,  and 
fish  consumption.  Environ  Res  1998;77:104-114. 

32.  Centers  for  Disease  Control  (CDC).  Mercury  exposure 
among  the  Miccosukee  Indian  tribe,  South  Florida,  unpub- 
lished report,  Atlanta:  CDC;  1993. 

33.  Mahaffey  KR,  Rice  GE.  Estimation  of  human  methyl 

mercury  exposure  to  the  general  US  population  and 
identified  subpopulations  through  the  consumption 
of  fish.  Appendix  H to  Volume  III,  Science  Advisory 
Board  draft.  An  Assessment  of  Exposure  from  Anthropo- 
genic Mercury  Emissions  in  the  U S:  Mercury  Study  Re- 
port to  Congress.  Report  #EPA452/R96001c.  Washing- 
ton: National  Technical  Information  Service;  1996. 

34.  Sherlock  JC,  Quinn  MJ.  Underestimation  of  dose-re- 
sponse relationship  with  particular  reference  to  the  re- 
lationship between  the  dietary  intake  of  mercury  and 
its  concentration  in  blood.  Hum  Toxicol  1988;7:129-132. 


J La  State  Med  Soc  VOL  152  February  2000  71 


Public  Health 


Appendix 

Louisiana  Mercury  Contaminant  Fishing  Advisories 


Parish 

Location 

Issue  Date 

Women  pregnant  or 
BREASTFEEDING  & CHILDREN  <7  YEARS 

Other  adults  & 
CHILDREN  >7  YEARS 

St  Tammany, 
Washington 

Pearl  River 

1/97 

No  bowfin  consumption. 

Limit  bass,  big  mouth  buffalo,  & freshwater 
drum  to  no  more  than  1 meal  a month. 

No  bowfin  consumption. 
No  consumption  limits 
on  other  species. 

Vermilion 

Seventh  Ward  Canal 

7/97 

Limit  bowfin,  flathead  catfish,  white  crappie, 
or  freshwater  drum  to  no  more  than  1 meal 
a month. 

No  consumption  limits. 

DeSoto 

Toledo  Bend  Reservoir,  north 
of  Pine  Island,  south  of 
Grand  Cane  Bayou  Toledo 
Bend  Reservoir, 

11/97 

Limit  bowfin,  white  crappie,  or  largemouth  bass 
to  no  more  than  1 meal  a month. 

No  consumption  limits. 

Sabine 

San  Patricio  arm  of  the  lake 

11/97 

No  bowfin  consumption. 

Limit  crappie  or  largemouth  bass  to  no 
more  than  1 meal  a month. 

Limit  bowfin  to  2 meals  a month 
No  limits  on  other  species. 

Vernon 

Lake  Vernon 

8/97 

Limit  largemouth  bass,  flathead  catfish,  redear  or 
bluegill  sunfish  to  no  more  than  1 meal  a month. 

No  consumption  limits. 

Gulf  of  Mexico 
waters  off  of  all 
coastal  parishes 

Gulf  of  Mexico 

9/97 

Limit  king  mackerel  39”  and  smaller  to 
1 meal  a month. 

No  consumption  of  king  mackerel  >39”. 

Limit  king  mackerel  39”  and 
smaller  to  4 meals  a month. 
No  consumption  of  king 
mackerel  >39”. 

St  James, 

Ascension, 

Livingston, 

St  John  the  Baptist 

Blind  River 

4/98 

Limit  bowfin  to  no  more  than  1 meal  per  month. 

No  consumption  limits. 

Acadia, 
Evangeline, 
St  Landry 

Bayou  des  Cannes 

10/97 

Limit  bowfin,  black  crappie,  or  freshwater 
drum  to  no  more  than  1 meal  a month. 

No  consumption  limits. 

Acadia, 

St  Landry 

Bayou  Plaquemine  Brule 

10/96 

No  bowfin  consumption. 

Limit  largemouth  bass,  crappie,  or  freshwater 
drum  to  no  more  than  1 meal  a month. 

Limit  bowfin  to  2 meals  a month. 
No  consumption  limit  on 
other  species. 

Evangeline 

Chicot  Lake 

5/97 

No  bowfin  consumption. 

Limit  largemouth  bass  to  no  more  than 
1 meal  a month. 

Limit  bowfin  to  2 meals  a month. 
No  consumption  limit  on 
other  species. 

Natchitoches 

Black  Lake 

10/96 

No  bowfin  consumption. 

Limit  bass  or  crappie  to  no  more  than 
1 meal  a month. 

Limit  bowfin  to  2 meals  a month. 
No  consumption  limit 
on  other  species. 

Ouachita, 

Union, 

Morehouse, 

Caldwell 

Ouachita  River:  LA/ARK 
border  to  lock  at  Columbia 

7/92, 

8/94 

No  bass  consumption. 

Limit  other  fish  species  to  no  more  than 
2 meals  a month. 

Limit  bass  to  2 meals  a month. 
No  consumption  limit  on 
other  species. 

Morehouse 

Bayou  Bartholomew 

1/99 

Limit  largemouth  bass,  spotted  bass,  black 
crappie,  channel  catfish,  freshwater  drum, 
& bigmouth  buffalo  to  no  more  than 
1 meal  a month. 

No  consumption  limits. 

St  Martin 

Henderson  Lake 

1/96 

Limit  largemouth  bass,  crappie,  or  freshwater 
drum  to  no  more  than  1 meal  per  month. 

No  consumption  limits. 

St  Tammany, 
Washington 

Bogue  Chitto  River 

8/96 

Limit  all  bass  species  or  bowfin  to  no  more 
than  1 meal  per  month. 

No  consumption  limits. 

St  Tammany 

Bayou  Liberty 

1/97 

Limit  largemouth  bass,  white  crappie,  black 
crappie,  freshwater  drum,  or  redear  sunfish  to  no 
more  than  1 meal  a month. 

No  consumption  limits. 

72  J La  State  Med  Soc  VOL  152  February  2000 


Public  Health 


Trade  M Bellanger  is  a senior  medical  student  at  Louisi- 
ana State  University  Health  Sciences  Center  in  New 

Orleans,  Louisiana. 

Erica  M Ceasar  is  a public  health  epidemiologist  with  the 
Louisiana  Department  of  Health  and  Hospitals,  Office  of 

Public  Health. 

Dr  Louis  Trachtman  is  the  Assistant  State  Health  Officer 
of  the  Louisiana  Department  of  Health  and  Hospitals, 

Office  of  Public  Health. 


Can  You  Help? 

The  Louisiana  State  Medical  Society  has 
discovered  that  bound  copies  of 
The  Journal  of  the  LSMS  for  the  years 
1988-1991  are  missing. 

We  would  like  to  maintain  our  library 
archives  by  rebinding  issues  for  the 
missing  years. 

If  you  have  copies  of  any  issue  of  The 
Journal  published  during  1988-1991  and 
would  like  to  contribute  to  this  effort, 
please  send  them  to  the  Managing  Editor, 
LSMS,  6767  Perkins  Road,  Baton  Rouge, 
LA  70808  or  call  (225)  763-8500. 


+ Tulane  = 

™'ftL|ASTER 

MLLMLI  M ADMINISTRATION 


We  are.  Whether  you're  already  in  the  healthcare 
field,  have  a business  or  liberal  arts  background,  Tulane 
can  give  you  the  unique  combination  of  business  and 
health  systems  skills  to  pursue  senior  management 
roles.  Tulane  offers  the  only  accredited  MHA  program 
in  the  area.  It's  where  quality  counts. 


What’s  standing 
between  you  and  the 
success  you  want? 


Weekend  Classes  (504)588-5469  www.hsm.tulane.edu/emha 


J La  State  Med  Soc  VOL  152  February  2000  73 


Public  Health 


Are  You  Sanitary? 

Louis  Trachtman,  MD,  MPH;  Bobby  Savoie,  MPH 


The  authors  present  an  annotated,  condensed  synopsis  of  the  fundamental  basis  of  public 
health  practice  in  Louisiana,  the  state's  Sanitary  Code.  The  "tongue-in-cheek"  remarks  about 
some  of  the  Code's  requirements  are  just  that,  poking  a bit  of  fun  at  the  rule  and  law-making 
processes,  but  meant  not  in  the  least  bit  to  underestimate  the  value  of  the  public  health  rules 
and  laws  of  the  state. 


What  a strange  question,  you  may  re- 
mark. Yet,  if  one  thinks  about  the 
definition  of  "sanitary",  it  is  most 
appropriate  to  think  of  "physician"  as  almost  a 
word-association  test  reflex  response  to  "sani- 
tary". The  definition,  according  to  Webster's 
Unabridged  Dictionary  is  "....of  or  relating  to 
health:  for  or  relating  to  the  preservation  or  res- 
toration of  health:  occupied  with  measures  or 
equipment  for  improving  conditions  that  influ- 
ence health:  free  from  or  effective  in  prevent- 
ing or  checking  an  agent  (as  filth  or  infection) 
injurious  to  health." 

The  early  physicians  of  Louisiana  made  no 
distinctions  between  public  health  and  medi- 
cal practice.  In  fact,  two  of  the  five  persons  on 
the  first  effective  Board  of  Health  in  New  Or- 
leans were  physicians.  This  was  in  1804.  The 


measures  adopted  by  the  Board  were  to  com- 
bat yellow  fever  epidemics.  This  was  success- 
fully accomplished  exactly  one  hundred  and 
one  years  later,  when  New  Orleans  had  its  last 
yellow  fever  epidemic.  Well,  Rome  was  not 
built  in  one  day  either,  was  it? 

Our  state's  Sanitary  Code,  a compilation  of 
laws  enacted  by  state  Boards  of  Health  and  by 
the  state  health  department,  is  a medical  prac- 
tice applied  to  the  entire  population  of  the  state. 
The  first  permanent  state  Board  of  Health  in 
the  United  States,  by  the  way,  was  established 
in  Louisiana  in  1855.  The  Code's  present  form, 
although  periodically  updated  and  revised, 
dates  from  1984.  Most  of  the  population  of  the 
state,  including  physicians  and  other  allied 
health  professional  persons,  have  never  seen 
it.  They  would  though  I am  sure,  if  asked,  be 


74  J La  State  Med  Soc  VOL  1 52  February  2000 


Public  Health 


able  to  identify  it  as  applicable  to  them.  How 
does  it,  though,  apply  specifically  to  the  phy- 
sician and  the  "everyday"  practice  of  medicine 
in  Louisiana? 

To  answer  that  question,  it  might  be  best  to 
start  at  the  beginning.  The  first  chapter  of  the 
Code  deals  with  "General  Provisions".  This  ex- 
plains how  the  State  Health  Officer,  who  is  al- 
ways a physician  licensed  to  practice  medicine 
in  Louisiana,  must  enforce  the  Sanitary  Code. 
This  work  is  generally  carried  out  by  licensed 
public  health  sanitarians  and  sometimes  by 
public  health  physicians,  nurses,  engineers, 
social  workers,  nutritionists,  and  other  allied 
health  professional  persons.  Public  health  is 
truly  a "team  effort"!  (About  how  many  other 
things  have  we  heard  that  phrase?  We  think  it 
started  here,  though.) 

This  chapter  also  deals  with  the  legal  pro- 
visions of  the  "due  process",  which  must  be 
followed  if  a violation  of  the  Code  is  to  be  en- 
forced. If  "due  processes"  are  not  followed,  en- 
forcement of  the  Code  just  falls  apart,  as  we 
have  seen  at  times  in  law  enforcement  in  the 
criminal  justice  system. 

Interestingly,  some  of  the  first  sanitarians 
in  Louisiana  back  in  the  19th  century  were 
called  "sanitary  police"  and  were  physicians. 

The  next  chapter  seems  to  be  where  most 
of  the  action  is  for  physicians  today.  It  is  called 
the  "Control  of  Diseases".  Ominous  in  scope, 
but  successful  in  intent  and  practice,  this  chap- 
ter defines  the  reportable  diseases  in  Louisi- 
ana, and  deals  with  extremely  important  mat- 
ters like  tuberculosis  quarantine  measures  (yes, 
still  done),  designation  of  yellow  fever  vacci- 
nation centers  (yes,  still  done),  immunization 
of  children  (yes,  still  done),  and  health  require- 
ments of  persons  working  in  day  care  centers 
and  residential  institutions.  Philosophically, 
one  might  think  modern  civilization  is  based 
on  successfully  enforcing  Chapter  II  of  the  State 
Sanitary  Code,  and  one  might  be  right  in  think- 
ing so! 

Each  year  a letter  is  sent  to  all  practicing 
physicians  licensed  in  Louisiana  reminding 
them  of  their  obligation  to  "report"  diseases 


on  that  "reportable"  list.  This  is  truly  the  back- 
bone of  the  control  of  epidemics  in  our  state, 
and  yes,  it  rests  on  the  physicians  of  the  state, 
who  make  the  all-important  diagnoses  in  their 
patients.  Other  health  care  professional  persons 
and  representatives  of  institutions  offering 
health  care  are  also  required  to  report  the  dis- 
eases. 

The  next  two  chapters  of  the  Code  are  con- 
cerned with  two  especially  critical  medical 
problems  in  the  state,  namely,  rabies  and  lead 
poisoning  Why  those  two?  I do  not  know. 
Suffice  it  to  say,  that  in  the  wisdom  of  many 
public  health  experts,  these  two  problems  are 
of  such  import,  that  they  deserve  separate 
chapters  of  the  Code  in  delineating  the  rules 
for  which  the  control  of  these  diseases  are  nec- 
essary. Although  hardly  a physician  in  the  state, 
hopefully,  will  be  faced  with  caring  for  a pa- 
tient with  rabies,  it  will  be  the  rare  physician 
who  is  not  asked  about  a patient's  being  bitten 
by  a potentially  rabies-prone  warm-blooded 
mammal.  The  Code  does  not  tell  the  physician 
how  to  make  the  decision  of  whether  to  treat 
prophylactically  or  not,  but  it  does  deal  with 
the  matters  of  requiring  rabies  vaccination  of 
dogs  and  cats,  and  the  authority  of  the  state 
health  officer  to  have  stray  animals  examined 
for  rabies. 

Likewise,  there  is  increasing  importance 
given  to  early  detection  of  elevated  blood  lead 
levels  in  children  and  construction  industry 
workers  exposed  to  lead.  Our  forefathers  were 
quite  wise,  when  they  coined  the  phrase,  "Get 
the  lead  out!"  After  what  may  be  many,  many 
years,  we  have  taken  these  words  to  heart.  The 
Code  goes  into  quite  a bit  of  detail  about  the 
inspections  necessary  and  required  if  a child  is 
found  with  an  elevated  blood  lead  level,  usu- 
ally as  a result  of  a "routine"  screening  blood 
test,  and  about  what  must  be  done  to  correct 
the  environmental  conditions  usually  found  as 
the  source  of  the  lead. 

Subsequent  chapters  of  the  Code  deal  with 
very  important,  but  for  the  modern  physician, 
perhaps  a bit  removed,  aspects  of  keeping  our 
environment  sanitary.  The  intent  of  this  trea- 


J La  State  Med  Soc  VOL  152  February  2000  75 


Public  Health 


tise,  however,  is  to  remind  you  of  the  impor- 
tance of  these  rules  to  the  practice  of  medicine, 
no  matter  how  skeptical  you  may  be. 

For  example,  what  would  our  quality  of  life 
be  if  public  health  regulations  did  not  discour- 
age mosquito-breeding  places,  or  rat-breeding 
places,  or  fly-breeding  places?  Worse  than  now, 
I am  sure  you  would  agree.  What  if  there  were 
no  rules  regarding  the  manufacturing,  process- 
ing, packing,  and  holding  of  drugs  and  food 
in  Louisiana?  'Taken  care  of  by  federal  law", 
you  may  say,  and  right  you  are.  For  foods  and 
drugs  manufactured  and  sold  only  in  Louisi- 
ana, though,  state  law  applies,  not  federal. 
States'  rights,  you  know.  Well,  that  is  why  state 
law  is  needed  in  the  Code  and  not  just  reliance 
on  federal  law. 

Because  there  are  many  entrepreneurs  in 
the  state  who  must  have  relatively  easy  access 
to  the  health  rules  and  regulations  regarding 
their  types  of  businesses,  many  chapters  of  the 
Code  are  arranged  to  facilitate  that  access. 
Therefore  there  are  chapters  dealing  exclu- 
sively with  frozen  desserts,  seafood  ("sea", 
here,  incidentally,  also  includes  food  from  fresh 
water),  and  game  bird  and  small  animal 
slaughter  and  processing.  For  us  laymen,  an 
example  of  a game  bird  would  be  a delicious 
guinea  hen  and  an  example  of  a slaughtered 
small  animal,  would  be,  and  promise  not  to  tell 
your  children,  rabbits.  Of  course,  if  animals  are 
slaughtered,  there  will  be  some  parts  that  are 
not  to  be  eaten,  and  must  be  disposed  of  in 
some  sanitary  manner.  This,  too,  is  a subject  in 
a chapter  of  the  Code. 

What  about  big  animal  slaughter,  logically 
you  may  ask.  Well,  that  is  a matter  governed 
by  the  laws  of  the  state's  Department  of  Agri- 
culture and  Forestry,  which  must  also  obey 
applicable  Code  regulations,  but  the  Depart- 
ment of  Agriculture  and  Forestry's  rules  and 
regulations  are  not  found  in  the  Code  itself. 
Cattle  are  raised  on  farms,  you  see,  and  that 
makes  it  agriculture.  Hey,  whoever  said  bu- 
reaucracy was  not  alive  and  well? 

The  extremely  important  chapters  govern- 
ing our  water  supplies,  sewage  disposal,  and 


related  matters  regarding  plumbing  follow  in 
the  Code.  What  could  be  more  basic  to  public 
health  than  having  clean  water  supplies  and 
sanitary  sewage  disposal?  This  led  many  early 
medical  critics  and  skeptics  of  public  health 
efforts  to  label  those  efforts  as  "....concerned 
with  nothing  but  sewers  and  drains".  Perhaps 
true  in  those  days,  and  still  extremely  impor- 
tant! 

In  keeping  with  trying  to  codify  rules  as 
applicable  to  certain  interested  parties,  there 
follow  chapters  of  the  Code  dealing  with  sani- 
tary requirements  of  hotels,  lodging  and  board- 
ing houses,  campsites,  public  buildings  and 
schools,  day  care  centers,  residential  facilities, 
institutions  including  jails  and  prisons,  hospi- 
tals, nursing  homes,  ambulatory  surgical  cen- 
ters, and  renal  dialysis  centers.  Physicians  who 
care  for  patients  in  the  institutional  settings 
mentioned,  both  out-patient  and  in-patient, 
will  be  keenly  aware  of  requirements  for  sani- 
tary conditions  in  those  places.  They  will  prob- 
ably be  involved  in  advising  on  "in-house" 
rules  to  safeguard  clean  environments  there, 
intimately  connected  with  the  well-being  of 
their  patients.  One  of  the  newer  requirements 
of  the  Code  is  the  safe  handling  of  potentially 
infectious  waste,  mostly  of  medical  origin,  in 
institutional  settings.  A whole  chapter  of  the 
Code  is  devoted  to  this  exclusively,  again  prob- 
ably because  of  the  singular  importance  of  the 
topic. 

The  safety  of  our  food  supply  is  of  vital 
concern  in  the  chapters  of  the  Code  dealing 
with  retail  food  stores  and  markets  and  eating 
and  drinking  establishments,  also  known  as 
restaurants  and  bars.  There  is  also  a chapter  of 
the  Code  dealing  with  regulations  of  tempo- 
rary food  services,  as  in  fairs  and  festivals,  for 
which  compliance  with  the  Code  is  voluntary. 
Which  physician  cannot  remember  from  medi- 
cal school  learning  of  the  perils  of  food-borne 
illnesses,  and  wondering  how  anyone  gets 
through  life  without  suffering  from  food  poi- 
soning caused  by  a vicious  member  of  one  of 
the  lower  phyla  of  micro-organisms  pathogenic 


76  J La  State  Med  Soc  VOL  152  February  2000 


Public  Health 


to  humans?  It  should  come  as  no  surprise,  that 
most  people  with  cases  of  food  poisoning  in 
these  modem  times  acquire  that  illness  in  home 
kitchens,  rather  than  in  restaurants,  which  are 
regulated  by  the  Code.  Cause  and  effect  there? 
Probably. 

Not  only  do  people  enjoy  themselves  at 
bars,  restaurants,  fairs  and  festivals,  but  also 
at  swimming  pools!  These,  too,  are  regulated 
by  the  Code,  with  a special  chapter  devoted  to 
the  sanitary  requirements  of  swimming  pools, 
and  both  "natural  and  artificial  bathing 
places". 

The  last  part  of  life,  ie,  death,  is  also  dealt 
with  in  the  Code.  Regulations  regarding  buri- 
als, disinterments  (yes,  still  happens  rarely), 
transportation  and  other  disposition  of  dead 
human  bodies,  form  a very  interesting  chapter 
of  the  Code. 

In  conclusion,  and,  about  time,  you  may 
say,  a Louisiana  physician's  medical  practice 
and  public  health  are,  perhaps,  just  as  insepa- 
rable today,  as  they  ever  were.  Our  very  way 
of  life  depends  on  preserving  public  health,  as 
we  know  it,  and  as  we  plan  for  it  for  the  fu- 
ture. This  article  has  tried  to  convince  you  of 
that  very  point. 


Dr  Trachtman  is  the  Assistant  State  Health  Officer  of  the 
Louisiana  Department  of  Health  and  Hospitals,  Office  of 

Public  Health  (LDHHPH). 

Mr  Savoie  is  Director,  Division  of  Environmental  Health 

of  the  LDHHPH. 


ADDRESS 

CHANGE? 


Mail  Us: 
Department  of 
Membership  & Finance 
6767  Perkins  Road 
Baton  Rouge,  LA  70808 

Call  Us: 

(225)  763-8500 
Fax  Us: 

(225)  763-2333 
e-mail  Us: 

membership@lsms.org 


J La  State  Med  Soc  VOL  152  February  2000  77 


Public  Health 


Public  Health  Education 
Opportunities  for  Physicians 

in  Louisiana 

Kim  B.  Overstreet,  MA 


Various  options  exist  for  physicians  and  other  mid-career  health  professionals  who  want 
additional  education  to  upgrade  their  credentials  in  the  public  health  arena  by  earning  de- 
grees or  working  toward  certification.  Potential  students  can  fit  distance  learning  classes 
into  full  schedules  by  participating  in  flexible  curriculums  that  offer  night  courses  through 
Internet  technology.  Other  programs  offer  course  material  that  physician-students  work 
into  their  own  schedules.  Some  traditional  programs  bring  health  professionals  into  the 
classroom  on  weekends  or  in  the  evening. 


Louisiana  physicians  and  other  health  care 
professionals  considering  a return  to  aca 
demies  have  a variety  of  options  avail- 
able to  them.  These  potential  students  may 
choose  from  educational  programs  that  employ 
technologies  associated  with  the  Internet  or  more 
traditional  campus-based  programs. 

Physicians  who  recognize  the  dramatic 
changes  taking  place  in  their  profession  are  see- 
ing further  education  as  a way  to  improve  their 
knowledge  of  the  health  care  industry  and  to 
network  with  other  health  care  professionals.  In 
addition,  additional  education  develops  possi- 
bilities for  advancement  in  management  or  the 
chance  to  learn  a new  body  of  information  to 
supplement  their  work.  Whether  they  are  seek- 
ing an  additional  degree  or  certification  in  a new 
discipline,  doctors  are  finding  that  educational 


institutions  are  developing  programs  that  are 
convenient  for  their  busy  schedules. 

"Distance  learning"  is  a term  that  describes 
a variety  of  approaches  to  teaching  material  to 
students  who  do  not  meet  in  a campus  classroom 
on  a regular  basis.  It  is  not  a new  educational 
technique — consider  the  fact  that  correspon- 
dence courses  have  been  available  for  decades. 
But  the  development  of  the  Internet  has  created 
new  interest  in  distance  learning.  Major  Ameri- 
can universities  such  as  Stanford,  Duke,  Johns 
Hopkins,  and  Tulane  have  developed  degree 
programs  that  are  taught  primarily  through  the 
Internet  with  students  making  minimal — if 
any — in-person  contact  with  their  professors. 

Most  discussions  about  online  pedagogy  are 
optimistic  and  upbeat  as  educators  adopt  and 
expand  the  technology  to  different  fields.  Dis- 


78  J La  State  Med  Soc  VOL  152  February  2000 


Public  Health 


tance  learning,  however,  is  not  for  every  student, 
but  it  appears  to  be  successful  for  the  highly  mo- 
tivated, goal-oriented  adult  learner.  Many  dis- 
tance learning  programs  require  computer  lit- 
eracy and  an  investment  in  an  up-to-date  com- 
puter, appropriate  peripherals,  and  software. 
Computer-literate  physicians  who  identify  them- 
selves as  independent  learners  and  are  consider- 
ing a return  to  the  classroom  can  consider  dis- 
tance learning  as  a highway  to  their  goals. 

Distance  learning  courses  are  taught  using 
online  and  off-line  technologies — or  a combina- 
tion of  both.  Online  learning  can  be  synchronous 
or  asynchronous.  In  synchronous  learning,  all  stu- 
dents enrolled  in  a course  sit  down  at  their  com- 
puters at  the  same  time  and  participate  in  the 
class,  listening  to  the  professor,  looking  at  appro- 
priate visuals,  and  possibly  communicating  with 
both  the  professor  and  the  other  students.  In  asyn- 
chronous learning,  students  tackle  coursework  on 
their  own  schedules,  in  some  programs  using  pre- 
recorded lectures. 

Both  synchronous  and  asynchronous  learn- 
ing use  e-mail  for  communication  among  class 
participants  as  well  as  between  the  professor  and 
students  on  a one-to-one  basis.  Web  sites  acces- 
sible by  a password  can  contain  course  syllabuses, 
class  notes,  pre-recorded  field  trips,  virtual  dis- 
sections, access  to  assigned  journal  articles,  re- 
lated links,  and  other  materials  relevant  to  the 
course.  Extended  class  discussions  can  go  on  for 
weeks  on  message  boards. 

Off-line  technologies  also  are  used  to  teach 
distance  learning  courses.  Soon  after  students  en- 
roll and  pay  tuition  for  their  courses,  they  receive 
through  snail-mail  a packet  of  CD-ROMs  (disks) 
and  other  software  that  present  course  material. 
Two-way  video  conferencing  and  audio 
conferencing  use  telephone  technologies  to  de- 
liver a course  from  the  professor's  location  to  a 
remote  site  like  a classroom  where  students  meet 
for  lectures  and  class  discussions. One-way  video 
broadcasting  sends  live  or  recorded  classes  by 
television  broadcast  or  satellite.  Students  can  par- 
ticipate in  live  broadcasts  through  the  telephone 
or  facsimile  machine. 


Physicians,  nurses,  and  other  health  profes- 
sionals who  work  in  occupational  health  pro- 
grams or  clinics  and  want  to  earn  a Master  of 
Public  Health  (MPH)  in  occupational  health 
should  consider  a new  distance  learning  program 
that  will  start  fall  semester  2000.  The  Center  for 
Applied  Environmental  Public  Health  (CAEPH) 
of  the  Tulane  University  School  of  Public  Health 
and  Tropical  Medicine  will  offer  the  new  program 
in  a context  similar  to  its  successful  MPH  in  oc- 
cupational health  and  safety  management  that 
began  fall  semester  1998. 

In  the  current  program  (the  schedule  for  the 
new  program  has  not  been  established),  students 
enroll  in  two  classes  each  semester  (fall,  spring, 
and  summer)  to  earn  the  degree  within  a two- 
year  period.  Enrollees  do  not  attend  any  part  of 
the  program  on  the  Tulane  campus.  Instruction 
is  conducted  through  the  synchronous  learning 
approach.  Two  nights  a week  (one  night  for  each 
class),  more  than  30  students  attend  real-time 
class  for  2 to  3 hours  over  the  Internet  by  logging 
on  to  the  program's  Web  site  and  accessing  an 
audio  conference  with  corresponding  screens  and 
teaching  aids. 

Interaction  among  the  professor  and  class 
participants  is  promoted  through  the  use  of  an 
instructor-centered  software  program  that  offers 
two-way  audio,  synchronized  Web  browsing,  an 
electronic  white  board,  text  chat,  on-line  student 
evaluations,  question  and  answer  sessions,  and 
other  features.  Further  interaction  results  from 
another  software  program  as  well  as  chat  rooms, 
bulletin  boards,  and  e-mail.  To  allow  for  techno- 
logical problems  or  scheduling  problems  for  stu- 
dents, sessions  are  recorded  so  students  can  later 
"play"  audio  portions  of  sessions,  which  are  syn- 
chronized with  the  instructional  material. 

To  guarantee  successful  communications, 
students  are  required  to  use  personal  computers 
that  meet  stringent  requirements  for  both  hard- 
ware and  software.  In  addition,  students  must 
be  computer  literate  and  able  to  use  the  required 
hardware  and  software  (Microsoft  Office, 
PowerPoint,  and  Windows  95)  when  the  program 
begins. 


J La  State  Med  Soc  VOL  152  February  2000  79 


Public  Health 


The  Tulane  program's  administrators  have 
been  impressed  by  the  quality  and  depth  of  in- 
teraction among  the  cohorts  enrolled  in  the  pro- 
gram. Although  current  students  reside  in  five 
time  zones  as  well  as  India,  and  most  have  never 
met  face  to  face,  they  have  developed  a profes- 
sional collegiality  as  profound  as  that  which  can 
develop  under  the  best  conditions  in  a tradi- 
tional program.  Concerns  that  the  curriculum 
would  not  be  as  challenging  as  Tulane' s tradi- 
tional MPH  programs  have  not  developed.  Par- 
ticipants describe  the  benefits  of  intellectual 
stimulation  as  well  as  the  immediate  opportu- 
nity to  apply  in  their  work  places  the  material 
they  have  learned. 

CAEPH  administrators  emphasize  that  dis- 
tance learning  is  not  effective  when  professors 
assume  they  can  teach  the  same  course  in  the 
same  manner  they  do  in  the  traditional  class- 
room. A courseware  specialist  works  with  pro- 
fessors to  understand  the  technology  and  the 
need  to  plan  far  ahead  for  sessions.  Materials 
must  be  prepared  ahead  of  time  for  broadcast 
and  for  students  to  access  on  the  Web  site.  Ex- 
perience gained  from  this  program  will  assist 
CAEPH  as  it  recruits  physicians,  nurses,  and 
other  mid-career  health  professionals  for  the 
new  MPH  program  in  occupational  health. 

In  1988,  the  Medical  College  of  Wisconsin 
(MCW)  began  granting  degrees  to  practicing 
physicians  who  maintain  existing  practices. 
MCW  offers  physicians  MPH  programs  in  health 
services  administration,  occupational  medicine, 
and  general  preventive  medicine.  On  any  given 
day,  more  than  300  physician-students  pursue 
work  in  the  programs.  Some  are  working  toward 
the  MPH,  but  others  are  earning  credit  in  the 
four  core  courses  required  by  the  American 
Board  of  Preventive  Medicine  to  establish  eligi- 
bility in  the  specialties  of  occupational  medicine 
and  of  public  health  and  general  preventive 
medicine. 

MCW  requires  its  distance  learning  students 
to  attend  a Saturday  orientation  session  in  Mil- 
waukee at  the  beginning  of  their  courses  and  to 
participate  in  commencement  exercises  at  the 
completion.  MCW  students  are  asynchronous 


learners;  they  enroll  in  one  course  at  a time  and 
are  encouraged  to  complete  it  within  a four- 
month  period  (approximately  150  hours  of 
study).  Students  plan  their  own  study  schedules 
and  can  complete  their  courses  faster  than  the 
four  months  allowed.  They  use  MCW's  Web  site 
for  review  quizzes  for  each  course  module,  gen- 
eral information  regarding  the  programs,  and 
other  online  learning  opportunities.  At  the  end 
of  a course,  students  take  a supervised  final  ex- 
amination at  the  MCW  campus  or  at  one  of  more 
than  600  cooperating  institutions  across  the  coun- 
try. 

A program  that  will  eventually  have  an  im- 
pact on  Louisiana's  health  care  industry  is  de- 
veloping for  students  at  the  Louisiana  State  Uni- 
versity Health  Sciences  Center  (LSUHSC)  in  New 
Orleans.  In  the  fall  of  1996,  the  Graduate  Studies 
Department  at  LSUHSC  began  to  offer  public 
health  courses  at  night  to  medical  students.  In 
1997,  business  courses  were  added  through  a 
partnership  with  the  University  of  New  Orleans 
(UNO).  During  these  organizing  years,  only 
medical  students  had  the  opportunity  to  pursue 
MPH  degrees,  and  they  were  required  to  com- 
plete the  MPH  degree  concurrently  but  separately 
from  the  medical  degree.  The  first  three  students 
to  complete  the  program  were  awarded  both  MD 
and  MPH  degrees  at  the  spring  1999  graduation 
ceremonies. 

In  fall  1999,  LSUHSC  expanded  eligibility  for 
the  MPH  program  to  include  all  medical,  dental, 
and  graduate  students.  Students  complete  nine 
core  courses  and  a research  project,  and  they  may 
concentrate  in  either  public  health  or  adminis- 
tration/management by  completing  three  elec- 
tives offered  in  these  two  subjects  (see  below). 
Students  pursue  their  primary  discipline  with 
public  health  as  a secondary  interest,  complet- 
ing both  degrees  within  the  same  period.  Plans 
for  the  future  include  opening  the  program  to  ad- 
ditional students. 

As  they  become  a part  of  the  Louisiana  health 
care  industry,  this  cadre  of  students — armed  with 
information  about  policy,  law,  computer  technol- 
ogy, and  administration  as  well  as  traditional 
epidemiology  and  measurement — will  constitute 


80  J La  State  Med  Soc  VOL  152  February  2000 


Public  Health 


a state-wide  network  of  providers  with  a com- 
mon public  health  education. 

Another  program  of  interest  to  medical  pro- 
fessionals started  fall  semester  1999  UNO.  The 
College  of  Business  Administration  initiated  a 
new  degree  of  interest  to  the  medical  community: 
the  master  of  health  care  management.  The  pro- 
gram attracts  career  health  care  professionals  who 
want  to  advance  in  their  fields,  develop  networks 
with  others,  and  add  to  their  knowledge  of  the 
health  care  industry.  Students  who  select  the 
Master  of  Health  Care  Management  program  at- 
tend evening  classes,  while  those  who  select  the 


Executive  Master  of  Health  Care  Management 
program  attend  classes  on  most  weekends  dur- 
ing the  thirteen-month  program. 

The  interdisciplinary  faculty  from  UNO's 
College  of  Business  Administration,  LSUHSC, 
and  lecturers  from  the  health  care  field  provide 
business  courses  such  as  accounting,  manage- 
ment, marketing,  economics,  and  finance  along 
with  courses  specific  to  the  health  care  indus- 
try. Graduates  are  prepared  to  work  at  a mana- 
gerial or  executive  level  in  both  public  and  pri- 
vate settings. 

The  Louisiana  Board  of  Regents  has  funded  a 


_ 

Required  and  Elective  Courses  for  Students  Earning  the  Concurrent  MD 
and  MPH  Degrees  at  LSUHSC  in  New  Orleans 

Required  Courses 

❖ Introduction  to  Medical  Informatics 

❖ Health  Law  and  Medical  Ethics 

❖ Principles  of  Epidemiology 

* Management  and  Health  Services 

❖ Introductory  Biostatistics 

❖ Health  Care  Policy 

❖ Environmental  Health  and  Medicine 

❖ Organizational  Behavior 

❖ Introduction  to  Measurement 
and  Evaluation 

❖ Research/Capstone  Project 

Elective  Courses  for  Administration  and 
Management  Concentration 

Elective  Courses  for  Public  Health  and 
Prevention  Concentration 

❖ Management  and  Health  Services  II 

❖ Intermediate  Epidemiology 

❖ Accounting  for  Health  Care  Managers 

❖ Intermediate  Biostatistics 

❖ Financial  Administration  in  Health 
Care  Settings 

❖ Design  of  Experiments 

❖ Applied  Research  Methods 

❖ Health  Care  Economics 

❖ Clinical  Preventive  Medicine 

❖ Health  Care  Marketing 

❖ Occupational  Health  & Medicine 

J La  State  Med  Soc  VOL  152  February  2000  81 


Public  Health 


project  to  reformat  two  courses — one  from  UNO 
and  one  from  LSUHSC — for  an  electronic  de- 
livery system.  The  pilot  courses — strategic  man- 
agement issues  in  the  health  care  industry  and 
environmental  health — began  in  summer  1999 
with  classes  of  graduate  and  medical  students 
from  the  two  institutions.  Ninety-minute  classes 
are  held  weekly  via  teleconferencing,  with  the 
remainder  of  the  course  work  on  an  Internet 
Web  site. 

At  its  best,  teleconferencing  promotes  teacher- 
to-student  and  student-to-student  interaction 
that  enhances  classroom  learning  and  provides 
time  structure  to  the  course.  Students  use  the 
Web  site  to  complete  assignments,  hold  discus- 
sions, attend  field  trips,  take  tests,  and  conduct 
research  at  convenient  times.  In  addition  to  giv- 
ing the  student  flexibility  in  scheduling  time  for 
work,  courses  on  the  Internet  provide  the  op- 
portunity to  include  more  material  than  can  be 
covered  in  traditional  classroom  instruction. 
Interfacing  the  Web  site  instruction  with  peri- 
odic teleconferencing  provides  more  structure 
than  a correspondence  course  and  encourages 
interaction  among  students  and  the  instructor. 


Internet  Web  Sites 
for  Further  Information 

❖The  Center  for  Applied  Environmental 
Public  Health,  Tulane  University  School 
of  Public  Health  and  Tropical  Medicine 
http:  / / www.caeph.tulane.edu 

❖University  of  New  Orleans 

College  of  Business 

http:/ / www.uno.edu/~coba/mhcm/ 

index.html 

❖Medical  College  of  Wisconsin 

http:  / / www.mcw.edu  / prevmed  / mph.html 

❖Association  of  Schools  of  Public  Health 
http:  / / www.asph.org 

V > 


Research  has  not  located  another  school  in 
the  country  that  combines  students  in  different 
disciplines,  faculty  from  different  institutions, 
and  the  use  of  teleconferencing  and  an  Internet 
Web  site  in  a health  education  program.  The  goal 
is  to  have  these  two  courses  available  on  the 
state's  distance  learning  system  by  summer  2000. 
This  type  of  delivery  system  has  potential  for 
graduate  education. 

Despite  optimistic  predictions  by  many  edu- 
cational administrators  for  virtual  education,  few 
anticipate  the  demise  of  traditional  undergradu- 
ate education.  Few  eighteen-year-olds  possess 
the  motivation  to  become  self-learners,  and  the 
traditional  student  benefits  from  the  social  con- 
text the  residential  campus  offers.  But  potential 
students  already  involved  in  a career  and  un- 
able to  take  off  a year  or  two  find  tempting  the 
option  of  a degree  or  certificate  as  close  as  their 
personal  computers.  Louisiana  physicians  think- 
ing about  returning  to  the  virtual  or  actual  class- 
room can  look  within  and  without  the  state  for 
professional  development. 


Kim  B Overstreet  is  a freelance  writer  and  editor  with 
an  interest  in  distance  learning  methods  and  issues. 

Most  of  her  editing  and  work  has  been 
in  the  area  of  diseases  affecting  marine  vertebrates 
and  invertebrates  \in  the  Gulf  of  Mexico. 


82  J La  State  Med  Soc  VOL  152  February  2000 


Public  Health 


Louisiana  Parish  Health  Profiles  1999: 
Using  Information  to  Drive  Local  Action 

Liz  Sumrall,  MPA;  Kate  McCaffery,  MPH; 

Madeline  Roberts,  MPH;  Elisabeth  Gleckler,  MPH 


The  Parish  Health  Profiles  1999,  published  by  the  Department  of  Health  and  Hospitals 
Office  of  Public  Health  (OPH),  are  intended  to  be  a source  of  parish-level  health  information 
to  be  used  for  community-level  planning.  The  third  edition  of  the  Profiles  uses  a broader 
definition  of  health  to  understand  the  quality  of  life  of  communities.  The  included 
information  represents  not  only  health  status,  but  also  other  aspects  of  quality  of  life,  such 
as  the  status  of  local  education,  economy,  environment,  and  crime  and  safety.  The  process 
of  collecting  this  information  yielded  two  additional  results:  strengthened  relationships 
amongst  information-providing  agencies  across  the  state  and  an  orientation  and  subsequent 
comprehensive  chapter  of  information  on  action  and  resources.  In  addition,  the  publication 
is  designed  to  be  reader  friendly,  with  a strong  emphasis  on  the  use  of  the  Parish  Health 
Profiles  to  aid  in  understanding  data.  The  Office  of  Public  Health  recognizes  that  the  Parish 
Health  Profiles  will  continue  to  evolve  to  meet  the  needs  of  their  audience.  In  order  to 
ensure  continuous  quality  improvement  through  future  editions,  the  Profiles  are  supported 
by  an  18-month,  multi-level  evaluation  process,  ensuring  consumer  and  user  input  and 
comment  at  different  levels. 


Taking  responsibility  for  one's  personal 
health  and  overall  improvements  in 
community  quality  of  life  are  increas- 
ingly salient  issues  in  today's  society.  Many 
public  health  agencies  and  practitioners,  as  well 
as  many  outside  of  the  traditional  public  health 
fields,  have  adopted  the  idea  of  "healthy  people 
in  healthy  communities"  as  their  guiding  light, 
balancing  individual  health  with  the  necessity 
of  community  improvement.  The  Parish  Health 


Profiles  1999  were  developed  by  the  Department 
of  Health  and  Hospitals  Office  of  Public  Health 
(OPH)  in  an  effort  to  share  this  perspective,  pro- 
vide valuable  health-related  information,  and 
enable  information-driven  individual  and  com- 
munity-level decision  making.  These  guiding 
purposes  highlight  the  necessity  of  placing 
health  information  in  context  with  other  social 
indicators. 


J La  State  Med  Soc  VOL  1 52  February  2000  83 


Public  Health 


Research  has  demonstrated  a strong  link  be- 
tween quality-of-life  issues,  such  as  the  economy, 
education,  and  the  environment,  and  the  health 
status  of  individuals.1  Furthermore,  public  health 
practitioners  have  long  recognized  that  by  work- 
ing towards  improving  the  environment  within 
which  people  live,  significant  improvements  can 
be  made  to  the  health  status  of  a population.  In 
recognition  of  this,  OPH,  along  with  public  health 
agencies  and  practitioners  locally  and  nationally, 
is  shifting  towards  a more  community-based  ap- 
proach to  health. 

At  the  same  time,  the  developers  of  the  Par- 
ish Health  Profiles  1999  recognize  that  information 
is  power.  As  the  state's  primary  health  informa- 
tion agency,  OPFf  understands  the  importance  of 
sharing  this  information  with  Louisiana  citizens 
in  a way  that  it  can  be  used  to  improve  health 
status.  The  cornerstone,  however,  is  that  commu- 
nity members  must  be  invested  in  community- 
based  processes  in  order  for  them  to  be  effective. 
It  was  in  this  spirit  that  the  new  Profiles  were  de- 
veloped and  written.  The  indicators  presented  in 
the  Profiles  are  those  which  met  a set  of  criteria 
for  relevance  to  community  level  action. 

This  article  discusses  the  development  of  the 
Profiles  and  explores  the  notion  of  how  quality- 
of-life  information,  when  available  in  an  under- 
standable and  useable  form,  can  empower  indi- 
viduals and  communities  to  improve  health  sta- 
tus and  overall  quality  of  life.  It  closes  with  a brief 
overview  of  the  multi-level  evaluation  plan  for 
the  Profiles,  which  will  provide  OPH  with  the  in- 
formation necessary  to  improve  the  Profiles  in  fu- 
ture editions. 

BACKGROUND 

Two  former  editions  of  the  Parish  Health  Profiles 
were  published  in  1992  and  1995.  These  books 
were  traditionally  intended  to  present  data  avail- 
able at  a parish  level  and  to  highlight  key  indica- 
tors of  local  health  status.  Over  the  past  decade, 
national  and  state  shifts  in  focus  from  individual 
and  population-based  health  intervention  to  com- 
munity-based action23  shine  a new  light  on  the 


context  in  which  health  information  is  presented 
and  used  and  on  who  is  using  it. 

DEVELOPMENT  PROCESS 
Target  Audience 

Community-level  leaders  such  as  directors 
of  community-based  organizations  (CBOs)  and 
local  elected  officials  were  identified  as  the  pri- 
mary target  audience  for  the  1999  Profiles.  It  was 
felt  that  that  group  of  people  was  the  one  most 
likely  to  serve  as  a catalyst  in  engaging  commu- 
nities to  use  this  information  at  a local  level.  Iden- 
tification of  the  target  audience  guided  decisions 
about  content,  framework,  and  which  character- 
istics were  necessary  to  make  the  document  more 
user  friendly.  Informal  discussions  with  repre- 
sentatives of  this  target  audience  underscored  the 
importance  of  providing  information  about  a 
broad  array  of  community  issues  in  an  accessible 
way.  These  discussions  also  provided  insight  into 
the  importance  of  providing  resources  for  fur- 
ther information  about  the  topics  discussed. 

OPH  Internal  Partners 

The  Profiles  development  process  involved  a 
broad  cross-section  of  OPH  staff.  A core  group 
defined  the  process  of  indicator  collection  and 
presentation  and  then  invited  all  public  health 
programs  to  submit  five  key  indicators  to  the 
Profiles.  The  programs  were  also  asked  to  sub- 
mit information  about  factors  which  affected  the 
performance  of  the  indicators,  ways  in  which 
community-level  action  could  be  taken  around 
the  indicators,  state  and  national  benchmarks  or 
goals  for  those  indicators,  and  local,  state  and 
national  resources  for  further  information. 

External  Partners 

In  order  to  present  a broad  definition  of 
health  and  quality  of  life,  it  was  critical  that  agen- 
cies and  departments  outside  of  OPH  provide 
additional  information  for  incorporation  into  the 
Profiles.  These  external  agencies  were  asked  to 
follow  a process  similar  to  the  one  outlined 


84  J La  State  Med  Soc  VOL  152  February  2000 


Public  Health 


above,  although  in  many  instances  an  attempt 
was  made  to  include  more  than  five  indicators 
from  these  resources.  These  partners  include 
the  DHH  Offices  of  Mental  Health,  Addictive 
Disorders,  Citizens  with  Developmental  Dis- 
abilities, Health  Services  Financing,  and  Re- 
search and  Development;  the  Louisiana  De- 
partment of  Social  Services;  the  Louisiana  Of- 
fice of  the  Governor  Elderly  Affairs  Council; 
the  Louisiana  Department  of  Economic  Devel- 
opment; the  Louisiana  Department  of  Educa- 
tion; the  Louisiana  State  Library;  the  Louisi- 
ana Department  of  Public  Safety  and  Correc- 
tions; the  Louisiana  Department  of  Culture, 
Recreation  and  Tourism;  the  Louisiana  Depart- 
ment of  Environmental  Quality;  the  Louisiana 
Coalition  for  the  Homeless;  Resources  for  In- 
dependent Living;  Louisiana  Electronic  Assis- 
tance Program  (LEAP)  Center  for  Business  and 
Economic  Research;  and  the  Louisiana  Turn- 
ing Point  Initiative.  All  external  partners  were 
invited  to  contribute  and  review  indicator  rec- 
ommendations and  resource  listings  from  their 
fields  of  expertise. 

Information  Summary 

In  all,  there  are  over  150  indicators  acces- 
sible in  this  publication.  In  addition  to  the  par- 
ish-specific data,  state,  regional,  and  national 
data  are  shared  both  for  the  purpose  of  com- 
parison points  and  to  suffice  where  no  parish- 
level  data  are  available.  Additionally,  where 
applicable,  national  Healthy  People  2000  goals 
are  included.  There  are  chapters  on  various 
topics,  such  as: 

♦>  Family  health; 

♦>  Infectious  disease; 

♦>  Chronic  disease  and  leading  causes  of 
death; 

♦>  Persons  with  disabilities; 

♦>  Mental  health; 

♦>  Equity  and  access-to-care; 

<♦  Education; 

❖ Environment; 

♦>  Economy;  and 

❖ Crime  and  safety. 


Within  these  chapters,  readers  will  find  indica- 
tors such  as: 

♦>  Percentage  of  low  birthweight  births; 

♦>  Percentage  of  births  receiving  early  prenatal 
care; 

❖ Teen  birth  rate; 

❖ Percentage  of  adults  who  are  current  smok- 
ers; 

❖ Percentage  of  women  over  50  who  have  had 
a mammogram  in  the  past  two  years; 

♦t*  Percentage  of  adults  over  age  65  receiving 
flu  shots; 

❖ Rate  of  sexually  transmitted  diseases; 

♦>  Rate  of  hepatitis; 

❖ Leading  causes  of  death  by  parish; 

♦>  Rate  of  firearm-related  deaths; 

❖ Percentage  of  parish  population  receiving 
Medicaid; 

♦>  Percentage  of  population  uninsured; 

♦>  Per  capita  income; 

❖ Unemployment  rates; 

❖ Estimates  on  homeless  populations; 

♦>  Percentage  of  high  school  students  dropping- 
out; 

❖ Percentage  of  enrolled  students  attending 
school; 

❖ Pounds  of  toxic  releases; 

♦>  Local  recycling  programs  and; 

❖ Much  more. 

Most  indicators  are  accompanied  by  a brief  dis- 
cussion of  what  affects  them  over  time. 

GUIDING  PHILOSOPHY 

The  Profiles  are  designed  to  encourage  commu- 
nity organizing  with  the  goal  of  supporting  com- 
munity decision  making  around  improving 
quality  of  life.  In  meeting  the  needs  of  the  target 
audience  as  consumers  of  health  information, 
three  introductory  chapters  were  dedicated  to 
discussion  about  health  and  a healthy  commu- 
nity, what  indicators  are  and  how  they  can  be 
used  and  interpreted,  and  what  a health  im- 
provement process  involves. 


J La  State  Med  Soc  VOL  152  February  2000  85 


Public  Health 


Health  in  a Healthy  Community 

The  discussion  in  this  chapter  is  intended  to 
provide  the  reader  with  an  understanding  of  the 
impact  of  all  the  aspects  of  community  and  so- 
cial life  on  health.  The  primary  arguments  are 
that  health  services  are  only  10  percent  of  the 
determinants  of  health4  and  that  behind  the 
causes  of  death  and  disease  are  attributable 
causes,  such  as  tobacco  use,  firearm  use,  micro- 
bial agents,  and  health-risk  behaviors.5  In  light 
of  these  two  arguments,  the  chapter  makes  a case 
for  a new  approach  to  improving  health  and 
quality  of  life:  this  approach  is  one  that  relies  on 
community-based  action  and  addresses  multiple 
aspects  of  community  life. 

Indicators 

The  developers  of  the  Profiles  understood  the 
necessity  of  a discussion  around  the  definition 
of  indicators.  This  chapter  fully  explains  how 
data  which  are  actionable  and  relevant  to  com- 
munity-level planning  can  be  selected  as  an  in- 
dicator. It  includes  a brief  discussion  of  epide- 
miological terms  and  standards,  as  well  as  crite- 
ria communities  can  use  to  select  indicators  for 
their  local  work. 

Turning  Information  Into  Action 

The  third  and  final  introductory  chapter  pre- 
sents an  overview  of  community  planning  pro- 
cesses. It  begins  with  information  collection  and 
moves  through  a discussion  of  elements  relevant 
to  communities  engaged  in  these  processes.  Part 
of  the  discussion,  based  on  a framework  from 
the  Himmelman  Consulting  Group,  is  an  analy- 
sis of  the  levels  of  communication  and  commit- 
ment and  corresponding  impacts  on  the  time, 
turf,  and  trust  of  community  partners.6 

VALUE-ADDED  PRODUCTION: 

A READER-FRIENDLY  APPROACH 

Based  on  research  done  in  the  development  of 
the  Profiles , it  became  evident  early  on  that  lead- 
ers of  CBOs  and  other  people  working  in  com- 


munities would  be  most  likely  to  use  the  Profiles 
effectively  and  continuously  if  the  information 
was  presented  in  a way  that  was  accessible  and 
friendly.  Reading  level,  publication  design,  and 
community  stories  and  ideas  were  identified  as 
high  priorities  for  reader  friendliness. 

Readability 

It  is  estimated  that  one  in  five  adults  in  the 
United  States  reads  at  or  below  a 5th  grade  read- 
ing level.7  In  response  to  statistics  such  as  that, 
public  health  practitioners  nationally  are  empha- 
sizing the  importance  of  writing  health  informa- 
tion publications  close  to  a 6th  grade  reading 
level.8  Initial  readability  tests  showed  that  the 
Profiles  began  at  a 1 7th  grade  reading  level  and, 
through  the  editing  process,  were  honed  down 
to  about  a 10th  grade  reading  level. 

Design 

The  design  of  the  Profiles  is  reader  friendly 
in  several  aspects.  First  and  foremost,  the  lay- 
out emphasizes  interesting  bits  of  information 
and  large  graphs  and  tables  of  data.  Informa- 
tion is  easy  to  find  both  on  the  page  and  through 
the  table  of  contents  and  the  index.  Further,  the 
book  is  effectively  cross-referenced.  Although 
the  chapters  contain  exclusive  data,  the  discus- 
sions around  factors  that  affect  indicators  often 
overlap.  Where  possible,  similar  discussions  in 
other  chapters  are  referenced  in  the  text. 

Community  Stories  and  Recommendations 

Two  elements  woven  throughout  the  Profiles 
represent  community  action.  The  first  is  a series 
of  story  boxes  called  'Taking  Care — Taking  Con- 
trol". These  boxes  contain  stories  from  commu- 
nity groups  and  representatives  who  are  work- 
ing on  improving  the  issues  discussed  in  the  text. 
For  example,  in  the  chapter  on  education,  the 
Assumption  Parish  Library  Board  is  highlighted 
for  its  work  in  establishing  an  adult  education 
center.  Individuals  are  also  represented,  includ- 
ing a mother  who  fought  to  get  special  educa- 
tion classes  for  her  autistic  child  and  a woman 


86  J La  State  Med  Soc  VOL  152  February  2000 


Public  Health 


whose  experience  with  breast  cancer  serves  as  a 
reminder  to  other  women  that  regular  self-exami- 
nations are  part  of  prevention. 

The  second  community  element  is  the  "The 
Community  Can"  box,  which  closes  each  chap- 
ter. In  this  box  are  ideas  for  community  and  in- 
dividual action  around  indicators  discussed  in 
the  chapter.  For  example,  the  chapter  on  chronic 
diseases  closes  with  suggestions  about  reducing 
tobacco  use,  improving  community  opportuni- 
ties for  regular  exercise  and  ways  to  advocate  for 
fresh  fruits  and  vegetables  in  local  groceries  and 
school  lunches. 

Product  Distribution 

Ease  of  access  to  information  is  key  to  implement- 
ing the  objectives  of  the  Parish  Health  Profiles  1999. 
A limited  number  of  hard  copies  will  be  printed. 
In  addition,  the  information  will  be  available 
through  the  DHH  website,  the  state  libraries,  and 
through  phone  contact  and  referrals  to  relevant 
sources.  The  Profiles  are  slated  for  release  in  the 
early  spring  of  2000. 

CONTINUOUS  QUALITY  IMPROVEMENT 

The  Office  of  Public  Health  has  made  a commit- 
ment to  design  and  implement  a thorough  evalu- 
ation process  for  the  1999  Parish  Health  Profiles. 
This  evaluation  has  several  levels.  The  informa- 
tion gathered  in  the  various  levels  of  evaluation 
activities  will  be  invaluable  in  refining  the  pro- 
cess and  future  editions  of  the  Parish  Health  Pro- 
files. From  these  activities,  OPH  will  build  a da- 
tabase of  Profile  users.  The  people  captured  in 
the  database  will  be  used  as  contacts  for  a fol- 
low-up at  the  6-,  12-,  and  18-month  marks  after 
production.  The  experiences  and  satisfaction 
level  of  these  people  will  help  OPH  to  determine 
the  usefulness  of  the  product  as  a resource  in 
community  health  improvement  activities. 

CONCLUSION 

The  Parish  Health  Profiles  1999  is  potentially  one 
of  the  most  complete  sources  of  quality-of-life 


information  compiled  and  published  at  a par- 
ish level.  OPH  decided  to  redevelop  the  Parish 
Health  Profiles  in  order  to  support  community- 
based  action  with  good  information  about  health 
and  quality  of  life,  as  well  as  to  provide  infor- 
mation about  other  communities  and  groups 
working  on  similar  issues.  The  production  pro- 
cess was  guided  by  a commitment  to  the  identi- 
fied target  audience  and  the  philosophy  behind 
community-level  improvement  and  understand- 
ing information.  The  evaluation  plan  is  a natu- 
ral extension  of  that  commitment  to  future  edi- 
tions of  the  Profiles.  The  power  of  information 
to  drive  community-level  action  and  improved 
quality  of  life  will  come  to  be  more  fully  appre- 
ciated through  these  processes. 

REFERENCES 

1.  Power  C,  Manor  O,  Matthews  S.  The  duration  and 
timing  of  exposure:  effects  of  socioeconomic  envi- 
ronment on  adult  health.  Am  J Public  Health 
1999;89:1059-1065. 

2 Institute  of  Medicine.  The  Future  of  Public  Health. 
Washington,  DC:  National  Academy  Press;  1988:35- 
55. 

3 Institute  of  Medicine.  Healthy  Communities:  New 
Partnerships  for  the  Future  of  Public  Health.  Washing- 
ton, DC:  National  Academy  Press;  1996:12-41. 

4.  Lalonde  M.  A New  Perspective  on  the  Health  of  Cana- 
dians: a Working  Document.  Ottawa:  Government  of 
Canada  Ottawa;  1974:31-37. 

5.  McGinnis  J,  Foege  W.  Actual  causes  of  death  in  the 
United  States.  JAMA  1993;270:2207-2212. 

6.  Himmelman  A.  Communities  Working  Collabo- 
ratively  For  a Change.  In:  Herrman  M.  Resolving 
Conflict:  Strategies  for  Local  Government.  Minneapo- 
lis; 1994:7-9. 

7.  National  Institute  for  Literacy.  1999.  Fast  Facts  on 
Literacy,  http:  / / www.nifl.gov.  (Keywords:  research 
and  statistics.) 

8.  Institute  of  Medicine.  Leading  Health  Indicators  for 
Healthy  People  2010:  Second  Interim  Report. 
Washington,  DC:  National  Academy  Press;  1999:19- 
42. 


Ms  Sumrall  is  Director;  Ms  McCaffery  is 
Communication  Service  Director;  and  Ms  Roberts  and 
Ms  Gleckler  are  Health  Communication  Specialists,  the 
Louisiana  Department  of  Health  and  Hospitals,  Office  of 
Public  Health,  Policy,  Planning  and  Evaluation. 


J La  State  Med  Soc  VOL  152  February  2000  87 


The  Journal  of  the  Louisiana  State  Medical  Society 
invites  members  to  submit  any  of  the 
following  items  for  publication: 

✓ Scientific  Studies 

</  Letters  to  the  Editor 

✓ Viewpoints 

* Socioeconomic  Papers 

* Medicolegal  Papers 

* Societal  Reports 

For  more  information,  contact  the  Editor,  Conway 
Magee,  MD,  at  (337)  439-8450  or  the  LSMS 
Department  of  Public  Affairs  at  (225)  763-8500. 

For  manuscript  specifications,  see  page  50, 
“Information  for  Authors”. 


88  J La  State  Med  Soc  VOL  1 52  February  2000 


Public  Health 


Louisiana  Rural 
Health  Access  Program 


Alice  LeBlanc,  MPH 


Louisiana  Rural  Health  Access  is  part  of  a Robert  Wood  Johnson  Foundation  project  to  ad- 
dress primary  and  preventive  medical  care  for  indigent,  uninsured  people  residing  in 
underserved  rural  parishes.  This  15-month  grant  funds  the  development  of  a pilot  program 
to  improve  access  to  health  care  in  Acadia,  Evangeline,  Iberia,  Lafayette,  St  Landry,  St  Mar- 
tin, St  Mary,  and  Vermilion  parishes.  Led  by  representatives  from  the  Department  of  Health 
and  Hospitals  and  the  Louisiana  State  University  Health  Sciences  Center,  team  committees 
designed  the  program's  innovative  use  of  telemedicine,  loan  development,  network  integra- 
tion, and  community  involvement.  A benefit  of  the  program  will  be  to  measure  the  out- 
comes of  each  objective  in  order  to  determine  which  intervention  works  best.  This  informa- 
tion will  be  invaluable  for  the  design  of  a five-year  rural  health  care  development  plan. 


There  were  nearly  2.2  million  hospital 
emergency  room  visits  in  Louisiana  dur 
ing  1996,1  the  equivalent  of  half  the 
state's  population  seeking  emergency  care. 

A natural  disaster  was  not  the  cause.  It  was 
an  ongoing  public  health  crisis,  judging  by  our 
state  rankings  (see  box  on  page  91). 

Indigent,  uninsured  people,  especially  those 
residing  in  Louisiana's  27  medically  under- 
served rural  parishes,  often  are  unable  to  ac- 
cess primary  and  preventive  medical  care.  This 
leads  to  multiple  emergency  room  visits  for  se- 
vere or  critical  medical  conditions.  Lack  of  early 


medical  access  also  causes  late  diagnoses,  poor 
prognoses,  increased  disability,  and  higher  mor- 
tality. 

The  Robert  Wood  Johnson  Foundation 
(RWJF)  recognized  the  gravity  of  this  problem 
in  eight  Southern  states  and  responded  by  cre- 
ating the  $13.9  million  Southern  Rural  Access 
Program. 

The  RWJF  initiative  provided  an  initial  $2.9 
million  round  of  funding  in  1999  to  improve 
access  to  medical  care  for  rural  residents  of  Ala- 
bama, Arkansas,  Georgia,  Louisiana,  Missis- 
sippi, South  Carolina,  Texas,  and  West  Virginia. 


J La  State  Med  Soc  VOL  152  February  2000  89 


Public  Health 


The  second  largest  award  in  this  funding  cycle 
was  made  to  Louisiana  State  University  Health 
Sciences  Center  (LSUHSC)  to  create  the  Louisi- 
ana Rural  Health  Access  Program  in  partnership 
with  the  Louisiana  Department  of  Health  and 
Hospitals. 

"LSU  Health  Sciences  Center  welcomes  the 
opportunity  the  Robert  Wood  Johnson  Founda- 
tion has  given  us  to  make  a significant  impact 
on  access  issues  in  Louisiana",  states  Dr  Mervin 
L.  Trail,  Chancellor  of  LSUHSC.  "Our  public  hos- 
pital system  provides  indigent  patients  a safety 
net  that  is  unique  in  the  country,  but  many  rural 
residents  are  not  able  to  reach  our  hospitals'  out- 
patient clinics.  Through  this  partnership  with 
DHH,  we  are  supporting  various  means  of  ex- 
panding primary  care  to  these  individuals." 

The  15-month  grant  funds  the  development 
of  a pilot  program  to  improve  access  to  health 
care  in  the  rural  medically  underserved  Acadia, 
Evangeline,  Iberia,  Lafayette,  St  Landry,  St  Mar- 
tin, St  Mary,  and  Vermilion  parishes.  This  South- 
west Louisiana  region  will  serve  as  a model  for 
the  rest  of  the  state. 

"By  facilitating  the  coordination  of  the  rural 
health  care  between  providers  and  the  unin- 
sured, we  plan  to  improve  the  referral  systems", 
states  David  L.  Hood,  Secretary  of  the  Louisi- 
ana Department  of  Health  and  Hospitals.  "This 
will  maximize  the  effectiveness  of  existing  pri- 
mary, secondary,  and  tertiary  care  centers,  an  ob- 
jective in  keeping  with  the  long-term  DHH  goal 
of  making  quality  health  care  accessible  to  all 
Louisiana  citizens." 

The  Louisiana  Rural  Health  Access  Program 
was  designed  with  the  representation  of  numer- 
ous state  constituencies.  One  group  was  the 
Management  Team,  which  designed  projects  in 
which  health  care  delivery  could  be  improved 
to  provide  access.  Led  by  representatives  from 
DHH  and  LSUHSC,  team  committees  designed 
the  program's  innovative  use  of  telemedicine, 
loan  development,  network  integration,  and 
community  involvement.  This  group  was  joined 
by  the  Partners  Advisory  and  Technical  Assis- 
tance Board,  a statewide  group  of  health  care 


providers  who  offered  practical  guidance  in  es- 
tablishing objectives. 

Since  there  are  many  facets  to  the  access 
problem,  the  Louisiana  program  targets  numer- 
ous objectives  simultaneously: 

❖ Organization  of  Chambers  of  Health,  loosely 
modeled  after  Chambers  of  Commerce, 
which  serve  as  the  locus  of  health  leadership 
development  and  community-health  plan- 
ning for  a parish-level  community; 

❖ Development  of  networks  of  existing  provid- 
ers throughout  the  pilot  area; 

❖ Establishment  of  a statewide  Rural  Health 
Development  Fund  to  assist  local  providers 
in  acquiring  loans; 

❖ Creation  of  a $3  million  capital  pool  for  fund- 
ing infrastructure  development  and  im- 
provements; 

❖ Provision  of  consultant  expertise  for  local 
and  statewide  program  development; 

❖ Construction  of  a website  of  grant  and  loan 
funding  clearinghouse  information; 

❖ Continued  primary  care  provider  recruit- 
ment and  retention  efforts  for  medically 
underserved  areas  of  the  state;  and 

❖ Design  of  a 5-year  rural  health  care  develop- 
ment plan. 

"Each  of  these  activities  will  impact  each 
other,  producing  a synergistic  effect  on  the  avail- 
ability of  primary  health  care  for  indigent  people 
in  rural  areas",  states  Marsha  Broussard,  MPH, 
Program  Director. 

The  Chamber  of  Health  involves  health  care 
professionals,  business,  civic,  religious  and  edu- 
cation leaders,  and  local  consumers.  Chamber 
members  participate  in  an  educational  orienta- 
tion regarding  gaps  and  barriers  to  primary 
health  care  in  their  community.  Guided  by  a co- 
ordinator, the  membership  develops  a list  of  pri- 
orities and  investigates  various  methodologies 
that  have  proven  effective  in  overcoming  these 
issues  in  other  areas. 

"Each  parish  may  define  different  issues," 
explains  Ms  Broussard.  "One  community  may 


90  J La  State  Med  Soc  VOL  152  February  2000 


Public  Health 


SHOWN  AT  THE  LOUISIANA  RURAL  HEALTH  ACCESS 
PROGRAM  KICKOFF  in  May,  1999  are  (l-r)  Dr  Mervin  L Trail, 
Chancellor  ofLSU  Health  Sciences  Center;  Michael  Beachler,  Director  of 
the  Robert  Wood  Johnson  Foundation  Southern  Rural  Access  National 
Program  Office;  and  David  L Hood,  Secretary  of  the  Louisiana  Department 
of  Health  and  Hospitals. 

seek  assistance  from  DHH  in  recruiting  a pri- 
mary care  physician.  If  the  newly  recruited  pro- 
vider needs  funds  to  establish  a practice,  we 
can  offer  assistance  in  applying  for  a loan.  Bank 
One  has  committed  to  work  in  concert  with 
local  rural  banks,  making  $10,000,000  available 
for  loans  through  the  Rural  Health  Develop- 
ment Fund." 

The  program  is  also  building  a $3  million 
capital  pool  for  infrastructure  development. 
This  type  of  loan  and  grant-making  pool  is  es- 
sential to  many  small  providers  who  may  not 
qualify  for  traditional  loan  programs. 

Additionally,  the  access  program  provides 
information  and  assistance  in  grant  seeking  and 
grant  writing  to  rural  projects  that  qualify  for 
government  and  philanthropic  funding  pro- 
grams. It  disseminates  information  regarding 
current  funding  opportunities,  via  e-mail  and 
fax,  to  interested  parties  and  is  in  the  process 
of  building  a website  for  this  purpose. 

Grant  support  also  involves  guidance 
through  the  grants  process — from  advice  in 
grassroots  coordination  of  project  organization 
to  direction  on  the  application  process. 

To  support  innovative  pilot  demonstrations 
and  small  analytical  projects,  the  Robert  Wood 
Johnson  Foundation  provided  $2.5  million  in 
funding  to  the  21s  Century  Challenge  Fund. 


Grant  awards,  ranging  between  $50,000  and 
$250,000,  will  be  made  in  the  next  2 years  to  sup- 
port projects  that  address  specific  health  care 
problems  or  increase  access  to  basic  health  care 
in  the  eight  Southern  Rural  Access  Program 
states.  Applicants  will  be  expected  to  secure  co- 
funding from  national,  regional,  or  local  philan- 
thropies and  other  public  or  private  sources. 

One  benefit  of  the  access  program  will  be 
measuring  the  outcomes  of  each  objective  and 
determining  which  interventions  work  best.  This 
information  will  be  invaluable  for  the  design  of 
a 5-year  rural  health  care  development  plan. 

Selecting  its  first  site  for  Louisiana's  access 
program  implementation  was  a major  decision. 
St  Mary  Parish  was  chosen  to  establish  the  first 
Chamber  of  Health  for  two  reasons.  First,  it  has 
a large  indigent  population  with  a high  level  of 
need;  second,  its  health  care  providers  are  a pro- 
active group  who  work  together  as  Bayou  Teche 
Community  Health  Network  (BYNET).  The 
BYNET  was  recently  awarded  a 3-year  $182,000 
Rural  Network  Grant  from  the  Federal  Office  of 
Rural  Health  Policy  to  formally  plan  network 
activities,  and  it  also  is  receiving  RWJF  techni- 
cal support  for  network  development.  The  group 
currently  consists  of  two  community  health  cen- 
ters, two  community  hospitals,  two  public  health 
units,  two  public  hospitals,  one  Indian  tribe,  and 
one  community  action  agency. 


How  Louisiana  Ranks 


49th:  Health  care  indicators2 

2nd:  Age-adjusted  death  rates  hy  all 

causes  at  582.9  per  100,000 
(US  rate  was  478.1  per  1,000,000)2 

5th:  Individuals  without  health 

insurance  (20. 9%)2 

2nd:  Poverty 1 

1st:  Lack  of  access  to  primary 

medical  care 2 


J La  State  Med  Soc  VOL  152  February  2000  91 


Public  Health 


Networks  optimize  resources  while  helping 
indigent  patients  navigate  their  way  through  the 
health  services  system.  The  providers  in  St  Mary 
have  found  a number  of  ways  to  do  this. 

Typically,  an  indigent  patient  may  be  work- 
ing (47.5%  of  the  nation's  working  poor  lack 
health  insurance3)  but  may  only  be  able  to  pay 
for  a primary  care  visit.  The  visit  is  not  usually 
for  a routine  checkup  but  for  treatment  of  an 
acute  condition  requiring  laboratory  or  radiol- 
ogy tests.  Those  costs  are  often  prohibitive  for 
the  patient.  The  BYNET  community  health  cen- 
ters' physicians  have  negotiated  limited  staff 
privileges  with  two  public  hospitals  to  prescribe 
radiology  and  laboratory  tests  for  their  patients 
at  these  facilities.  The  patients  access  the  hospi- 
tal services  at  a pro-rated  basis  or  no  charge  and 
then  return  to  their  health  center  physician's 
care,  averting  the  cost  to  the  hospital  of  provid- 
ing clinic  follow-up. 

Many  indigent  patients  have  no  transporta- 
tion to  reach  specialists  in  a larger  city  — and 
they  often  do  not  have  paid  leave  to  afford  a day- 
long journey.  To  alleviate  this  problem,  LSUHSC 
has  committed  its  support  for  the  establishment 
of  a $136,800  Telemedicine  studio  to  link  St  Mary 
Parish  with  specialty  consults  from  a hub  site. 

Although  the  access  program  has  focused  its 
first  Chamber  of  Health  efforts  on  St  Mary  Par- 
ish, the  program  is  supportive  of  numerous  other 
initiatives  throughout  the  state. 

The  Louisiana  Rural  Hospital  Critical  Access 
Program  has  been  established  by  a recent 
$220,000  award  to  DHH  under  the  Medicare  Ru- 
ral Hospital  Flexibility  Program.  A maximum  of 
17  eligible  Louisiana  hospitals  may  apply  for 
funding  from  this  grant  to  conduct  feasibility 
studies  regarding  their  participation  in  this  pro- 
gram. Hospitals  would  be  required  to  reduce 
capacity  to  15  beds  in  order  to  qualify  for  this 
Medicare  Cost-Based  Reimbursement  Program 
which  also  subsidizes  ER  physician  salaries. 

The  Louisiana  Office  of  Public  Health,  in  as- 
sociation with  The  Louisiana  Turning  Point  Ini- 
tiative, funded  by  RWJF  and  Kellogg  Founda- 
tion, is  engaged  in  a statewide  analysis  of  health 
care  access  and  coverage.  The  Louisiana  Primary 

32  J La  State  Med  Soc  VOL  152  February  2000 


Care  Association  is  using  a $25,000  grant  from 
the  Bureau  of  Primary  Care  (BPC)  to  fund  a state- 
wide market  assessment  of  community  health 
center  opportunities  to  build  networks  and  to 
participate  in  managed  care  and  shared  provider 
agreements.  The  Iberia  Comprehensive  Health 
Center  received  a $75,000  BPC  grant  to  partially 
fund  an  outreach  program  for  Asian  Americans, 
and  the  David  Raines  Community  Health  Cen- 
ter in  Shreveport  is  developing  a Rural  Inte- 
grated Delivery  System  with  BPC  funding. 

"The  Louisiana  Rural  Health  Access  Pro- 
gram is  committed  to  supporting  the  concerted 
efforts  of  providers,  community  groups,  and 
funding  agencies  to  address  the  issues  that  limit 
care",  states  Ms  Broussard.  "This  can  lead  to 
major  improvements  in  our  health  service  de- 
livery system.  By  working  together  we  can  use 
existing  resources  more  effectively,  help  medi- 
cally underserved  communities  attract  primary 
care  providers,  identify  and  acquire  new  fund- 
ing streams,  and  build  referral  systems  that  en- 
sure a seamless  quality  of  care." 

"Our  ultimate  goal",  concludes  Ms 
Broussard,  "is  to  improve  the  health  and  lives 
of  indigent  people  throughout  rural  Louisiana." 

The  Louisiana  Rural  Health  Access  Program 
may  be  reached  at  LSUHSC  (504)  680-9352. 


BAYOU  TECHE  COMMUNITY  HEALTH  NETWORK  (BYNET)  members 
are  shown  at  a meeting  with  Louisiana  Rural  Health  Access  Program 
(LRHAP)  staff.  Standing  (1-r)  are:  Dr  Brian  Amy  and  Becky  Scheuermann 
of  OPH  Region  IV;  Paul  Landry,  DHH  LRHAP  Network  Coordinator; 
Marsha  Broussard,  LRHAP  Director;  Patti  DiMichele,  Director  of  the 
Louisiana  Health  Care  Campaign;  Gail  Davis,  Director  of  the  Iberia 
Comprehensive  Care  Center;  Dr.  Gary  Wiltz,  Bayou  Teche  Action  Center 
Medical  Director;  and  Fred  Duplechin,  Administrator  of  OPH  Region 
III.  Seated  (1-r)  are:  Alice  LeBlanc,  LSU  Health  Sciences  Center;  Anne 
Witmer,  Director  of  Louisiana  Turning  Point;  Sharon  Gauthe,  OPH  Region 
III;  and  Carla  Broussard-Pellerin,  Director  of  the  Bayou  Teche  Action 
Center. 


REFERENCES 


1.  Bureau  of  Health  Care  Delivery.  Morgan  KO, 
Morgan  S (Editors).  Health  Care  State  Rankings  1998: 
Health  Care  in  the  50  United  States,  6th  Edition. 
Lawrence,  Kan:  Morgan  Quitno  Press;  1998. 

2.  State  of  Louisiana  Department  of  Health  and 
Hospitals  Louisiana  Center  for  Health  Statistics. 
Wiles  S (Editor).  1999  Louisiana  Health  Report  Card. 
New  Orleans,  La:  Louisiana  State  University  Health 
Services  Center  Auxiliary  Enterprises;  1999. 

3.  US  Census  Bureau.  Campbell  J.  Health  Insurance 
Coverage  1998.  Washington,  DC:  Government 
Printing  Office;  1999.  (Publication  no  P60-208). 


Ms  LeBlanc , MPH,  is  a Clinical  Instructor  in  the 
Department  of  Public  Health  and  Preventive  Medicine  at 
Louisiana  State  University  Health  Sciences  Center,  New 
Orleans,  Louisiana.  She  also  serves  as 
Grants  and  Contracts  Manager  for  the 
Louisiana  Rural  Health  Access  Program. 


Calendar 

MARCH  2000 


1 HCFA  Medicare  Part  B Update 
Workshops 

12  Workshops  held  throughout  Louisiana 
from  February  15  until  April  11.  Contact: 
Michelle  DeSoto  (225)  231-2150. 

4-6  15th  Annual  Mardi  Gras  Anesthesia 
Update 

New  Orleans,  La.  Contact:  Judy  Lua 
Esporotu,  Tulane  University  School  of 
Medicine,  1430  Tulane  Ave.,  New  Orleans, 
LA  70112,  phone:  (800)  588-5300,  (504) 
588-5466,  e-mail:  cme@tulane.edu. 

9 STD  Grand  Rounds:  Genital 

Dermatology 

Dallas,  Tex.  Contact:  Mabel  Davis,  STD/ 
HIV  Prevention  Training  Center,  Dallas 
County  HHS,  2377  N.  Stemmons  Freeway, 
Suite  #426,  Dallas,  TX  75207,  internet: 
http://www.stdptc.us.edu. 

10  Loyd  C.  Megison,  Jr.  Visiting 
Professorship:  Michael  LJ  Apuzzo,  MD, 
“The  Reinvention  of  Neurosurgery” 

Shreveport,  La.  Contact:  Paula  Bloom, 
1501  Kings  Highway,  Shreveport,  LA 
71130,  phone:  (318)  675-5392,  e-mail: 
pblooml  @lsumc.edu. 

12-15  5th  Annual  National  Meeting  of  the  IPA 
Association  of  America 

Las  Vegas,  Nevada.  Contact:  TIPAAA, 
phone:  (510)  569-6561,  fax:  (510)  569- 
2753,  e-mail:  tipaaa@aol.com. 

14-17  12th  National  HIV/AIDS  Update 
Conference:  HIV/AIDS  at  the 

Crossroads-Confronting  Critical  Issues 

San  Francisco,  Cal.  Contact:  American 
Foundation  for  AIDS  Research  (amfAR), 
internet:  www.amfar.org/nauc. 


24-26  National  Rural  Health  Association  23rd 
Annual  Conference 

New  Orleans,  La.  Contact:  NRHA,  phone: 
(816)  756-3140,  internet:  http:// 

www.nrharural.org. 

27-29  NIH  Consensus  Development 
Conference  on  Osteoporosis 

Bethesda,  Md.  Contact:  Conference 
Registrar  (301)  592-8600. 

29-2  2000  International  Conference  on 

Physician  Health:  “Recapturing  the 
Soul  of  Medicine” 

Charleston,  SC.  Contact:  Roger  Brown, 
PhD,  AMA  Science  and  Public  Health 
Advocacy  Programs,  phone:  (800)  621- 
8335,  (312)  464-5066,  fax:  (312)  464- 
5841. 


April  2000 


10-14  29th  Family  Practice  Update 

New  Orleans,  La.  Contact:  Kathleen 
Melancon,  Louisiana  State  University 
Health  Sciences  Cener,  Institute  of 
Professional  Education,  phone:  (504)  568- 
5272,  e-mail:  cme@lsumc.edu. 

24  Louisiana  Legislative  Session  Begins 

27-29  10th  Annual  Endocrinology  Update 

New  Orleans,  La.  Contact:  Jocelyn  Arnold, 
Alton  Ochsner  Medical  Foundation,  e-mail: 
jarnold@ochsner.org,  phone:  (504)  842- 
3702. 

29-30  Annual  Tri-State  Anesthesiology 
Conference 

New  Orleans,  La.  Contact:  Jocelyn  Arnold, 
Alton  Ochsner  Medical  Foundation,  e-mail: 
jarnold@ochsner.org,  phone:  (504)  842- 
3702. 


94  J La  State  Med  Soc  VOL  152  February  2000 


LSMS  MEETINGS 


MARCH  2000  APRIL  2000 


7 Mardi  Gras  8 CME  Accreditation  Committee 

10:00  am 

11  Chronic  Diseases  Committee 

1 0:00  am  23  Easter 

14  Physicians  Health  Foundation  of  LA  BOT  24  Louisiana  Legislative  Session  Begins 

6:30  pm 

15  Board  of  Governors 
8:30  am 

Medical  Disclosure  Panel 
1 :30  pm 

25-28  AMA  Leadership  Conference  (Unless  indicated  otherwise,  all  meetings  are 

Miami,  Fla  at  the  LSMS  Headquarters.) 


l SRC  1/ 

1 

Because  this  is  no  place 
for  a doctor  to  operate. 


To  reach  vour  local  office, 
call  1-800-344-1899. 

medicalprotective.com 


The  Medical  Protective  Company ? 


J La  State  Med  Soc  VOL  152  February  2000  95 


Advertisers 


Diagnostic  Imaging Inside  Front  Cover,  Outside  Back  Cover 

Gachassin  Law  Firm 58 

LAMMICO Inside  Back  Cover 


Medical  Protective  Company 95 

The  Trust  Company 53 

Tulane  University 73 


98  J La  State  Med  Soc  VOL  152  February  2000 


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Avenue  C-Marrero  925  Avenue  C 
Practice  Accredited  by  the  American  College  of  Radiology 


ESTABLISHED  1844 


Of  the  Louisiana  State  Medical  Society 


HS/HSL 

UillVERinY  Of  MARYLAND, AT 
BALTIMORE  4 


1999  Annual  Report 
of  the  Louisiana  State  Medical  Society 


Appearances  are  Deceiving 
Abdominal  Mass 

The  Otologic  Manifestations  of  Barotrauma 
Partial  Colectomy  Required  for  Resection  of  Renal  Cell  Carcinoma 
Diagnosis  and  Management  of  Painful  Thyroid  Nodule  in  a Patient  with  Systemic  Sarcoidosis 


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FDA,  peripheral  MR  Angiography  studies  of  the 
lower  extremities  are  greatly  improved  and  can 
serve  as  an  alternative  to  invasive  conventional 
angiography.  Medicare  now  provides 
coverage  and  has  approved  MRA 
as  an  appropriate  test  in  determining 
the  extent  of  peripheral  vascular 
disease  in  the  lower  extremities. 
Additionally,  MRA  has  been  shown  to  find 
occult  flow  in  blood  vessels  where  it  was  not 
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MRA  is  a non-invasive  test  and  requires 
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■ Diagnostic 
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Specialists  in  Outpatient  Radiology 

Tenet  Louisiana  HealthSystem 

Uptown  3437  Prytania  St.  • Metairie  3625  Houma  Blvd. 

Marrero  925  Avenue  C 

Practice  Accredited  by  the  American  College  of  Radiology 


Editor 

CONWAY  S.  MAGEE,  MD 

Chief  Executive  Officer 

DAVE  TARVER 

General  Manager 

CATHY  LEWIS 

Managing  Editor 

ANNE  SHIRLEY 


Administrative  Assistant 

MELISSA  CANTRELL 

Advertising  Sales 

ANNE  GOOCH 

BOARD  OF  TRUSTEES 
Chairman,  CONWAY  S.  MAGEE,  MD 
K.  BARTON  FARRIS,  MD 
EMILE  K.  VENTRE  JR,  MD 
Ex  officio,  C.  Clinton  Lewis,  MD 

EDITORIAL  BOARD 
A.  JOANNE  GATES,  MD 
RODNEY  C.  JUNG,  MD 
PATRICK  W.  PEAVY,  MD 
TRENTON  L.  JAMES  II,  MD 
JACK  P.  STRONG,  MD 
CLAY  A.  WAGGENSPACK  JR,  MD 
WINSTON  H.  WEESE,  MD 

LSMS  BOARD  OF  GOVERNORS 
C.  CLINTON  LEWIS,  MD 
DUDLEY  M.  STEWART,  MD 
KEITH  DESONIER,  MD 
LEO  L.  LOWENTRITT  JR,  MD 
K.  BARTON  FARRIS,  MD 
RUSSELL  C.  KLEIN,  MD 
WALLACE  H.  DUNLAP,  MD 
VINCENT  A.  CULOTTA  JR,  MD 
RICHARD  J.  PADDOCK,  MD 
BARRY  G.  LANDRY,  MD 
WILLIAM  T.  HALL,  MD 
JOSEPH  BUSBY  JR,  MD 
LYNN  Z.  TUCKER,  MD 
R.  MARK  WILLIAMS,  MD 
MARTIN  B.  TANNER,  MD 
MARTIN  J.  DUCOTE  JR,  MD 
MARCUS  L.  PITTMAN  III,  MD 
CHARLES  D.  BELLEAU,  MD 
JOSHUA  LOWENTRITT,  MD 
LAURA  BRESNAHAN 

ESTABLISHED  1844.  Owned  and  edited  by  the 
Journal  of  the 
Louisiana  State  Medical  Society , Inc.. 
6767  Perkins  Road,  Baton  Rouge,  LA  70808; 
phone:  (225)  763-2310;  fax  (225)  763-2332. 

e-mail:  publicaffairs@lsms.org 
Internet:  www.lsms.org 

Copyright  2000  by  the  Journal  of  the 
Louisiana  State  Medical  Society.  Inc. 

Subscription  price  is  $35  per  year  in  advance, 
postage  paid  for  the  United  States; 
$50  per  year  for  all  foreign  countries 
belonging  to  the  Postal  Union. 

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Postmaster:  Send  address  changes  to 
6767  Perkins  Road,  Baton  Rouge,  LA  70808. 

The  Journal  of  the  Louisiana  State  Medical  Society 

(ISSN  0024-6921)  is  published  monthly 
at  6767  Perkins  Road,  Louisiana  State  Medical  Society, 
Baton  Rouge,  LA  70808. 
Periodical  postage  paid  at  Baton  Rouge,  LA 
and  additional  mailing  offices. 

Articles  and  Advertisements  published  in  the  Journal 
are  for  the  interests  of  its  readers  and  do  not 
necessarily  represent  the  official  position  or 
endorsement  of  the  Journal  of  the  Louisiana 
State  Medical  Society,  Inc.  or  the 
Louisiana  State  Medical  Society. 

The  Journal  reserves  the  right  to  make  the  final 
decision  on  all  contents  and  advertisements. 


Of  the  Louisiana  State  Medical  Society 


Journal 

ISSlP§i?|! 

it  m 

«?sr 


4 | ^ 

nUAL  PCfEPOR  f 

Supplement 

2 

1999  LSMS  Leadership 

3 

Report  of  the  President 

7 

Secretary/Treasurer 

8 

Board  of  Governors 

13 

Board  of  Councilors 

14 

Budget  and  Finance 

19 

Council  on  Legislation 

28 

AMA  Delegation 

32 

LAMPAC 

33 

ERF 

34 

PHFL 

35 

Department  Reports 

50 

Reports  of  Committees 

50 

Proceedings  of  the  HOD 

56 

Resolutions 

71 

2000  Budget 

73 

President’s  Address 

77 

Inaugural  Address 

80 

1999  Delegates 

83 

LSMS  Staff 

Karen  Crotty,  MD 

119 

Partial  Colectomy  Required  for 

Joseph  N.  Macaluso  Jr,  MD 

Resection  of  Renal  Cell  Carcinoma: 

A Case  Report  and  Review  of  Treatment 
Options  for  Locally  Advanced  Disease 

Lester  W.  Johnson,  MD 

125 

Diagnosis  and  Management  of  a Painful 

James  K.  Sehon,  MD 

Thyroid  Nodule  in  a Patient  with  Systemic 

John  C.  McDonald,  MD 

Sarcoidosis 

100 

INFORMATION  FOR  AUTHORS 

C.  Clinton  Lewis,  MD 

101 

PRESIDENT’S  MESSAGE 
2000  Legislative  Session 

Jorge  1.  Martinez-Lopez,  MD 

104 

ECG  OF  THE  MONTH 
Appearances  are  Deceiving 

James  P.  Lacey,  MD 

107 

OTOLARYNGOLOGY/HEAD  & NECK 

Ronald  G.  Amedee,  MD,  MPH 

SURGERY  REPORT 

The  Otologic  Manifestations  of  Barotrauma 

Sanjay  M.  Patel,  MD 

112 

RADIOLOGY  CASE  OF  THE  MONTH 

Janis  Letourneau,  MD 
Harold  Neitzschman,  MD 

Abdominal  Mass 

Gustavo  A.  Colon,  MD 

114 

THE  JOURNAL  150  & 100  YEARS  AGO 
March  1850  and  1900 

128 

CALENDAR 

130 

CLASSIFIED  ADVERTISING 

Eugene  New 
New  Orleans 


J La  State  Med  Soc  VOL  152  March  2000 


99 


Information  for  Authors 


The  Journal  is  published  for  the  benefit  of  the  members  of  the  Louisiana  State 
Medical  Society.  Manuscripts  should  be  of  interest  to  a broad  spectrum  of 
physicians  and  designed  to  provide  practical  information  on  the  current  status 
and  the  progress  and  changes  in  the  field  of  clinical  medicine.  The  articles 
published  are  primarily  original  scientific  studies  but  may  include  societal, 
socioeconomic,  or  medicolegal  topics. 

Review  Process 

Each  submission  is  reviewed  by  the  editor  and  is  subject  to  peer  review  by  one 
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The  final  decision  to  accept  or  revise  falls  to  the  editor. 

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Allow  margins  of  at  least  1 inch  on  all  sides;  avoid  end-of-line  hyphens;  num- 
ber all  pages,  starting  with  the  title  page;  begin  each  major  part  of  the  manu- 
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manuscript  in  triplicate. 

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and  (3)  a reference  to  a part  of  a larger  work. 

1 . Brush  JE  Jr,  Cannon  RO  III,  Schenke  WH,  et  al.  Angina  due  to  coro- 
nary microvascular  disease  in  hypertensive  patients  without  left  ven- 
tricular hypertrophy.  N Engl  J Med  1988;319:1302-1307. 

2.  Hajdu  SI.  Pathology  of  Soft  Tissue  Tumors.  Philadelphia,  Pa:  Lea  & 
Febiger;  1979:60-83. 

3.  Robinson  BH.  Lactic  acidemia.  In:  Scriver  CR,  Beaudet  AL,  Sly  WS, 
et  al  (editors).  The  Metabolic  Basis  of  Inherited  Disease , 6th  edition. 
New  York:  McGraw-Hill;  1989:869-888. 

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the  editorial  process,  write  the  Editor  or  the  Managing  Editor  as  below.  Or, 
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Editor,  Journal  of  the  Louisiana  State  Medical  Society 
6767  Perkins  Rd. 

Baton  Rouge,  LA  70808 


100  J La  State  Med  Soc  VOL  152  March  2000 


■ 1 ■ ■ ■ — ^^^0 


Member  Communication, 
Involvement  Vital  for 
LSMS  Success 

C.  Clinton  Lewis,  MD 


The  Louisiana  State  Medical  Society  ex- 
ists for  Louisiana  physicians  and  for 
our  patients.  We  ask  all  of  our  mem- 
bers to  tell  their  colleagues  how  important  it  is 
to  speak  as  one  voice  to  be  heard  in  Baton 
Rouge  and  in  Washington.  Numbers  count  in 
politics.  The  reality  is  that  the  more  members 
we  have,  the  more  attention  we  will  receive. 

We  are  trying  to  inform  our  members  as 
quickly  and  completely  as  we  can  by  the 
Internet,  as  well  as  through  our  regular  publi- 
cations. In  the  area  of  the  Louisiana  state 
healthcare  budget,  the  facts  are  constantly 
changing,  but  we  and  our  staff,  especially  our 
Office  of  Governmental  Affairs,  try  to  stay  cur- 
rent as  much  as  it  is  humanly  possible. 

Medicaid  reimbursement  is  important  to 
most  of  our  doctors.  At  present  levels,  many,  if 
not  most  of  our  physicians  lose  money  seeing 
Medicaid  patients,  considering  practice  over- 
head costs.  Any  more  cuts  by  the  state  will  force 
many  of  us  to  cease  participation  in  the  Med- 
icaid Program,  with  obvious  impact  on  avail- 
ability of  care  for  the  citizens  of  Louisiana. 

We  are  trying  to  provide  information  on 


Workers'  Compensation  requirements  as  they 
change.  Working  together  we  may  have  some 
impact  on  changes  to  make  the  program  more 
user-friendly.  In  the  meantime,  we  will  try  to 
keep  those  of  us  involved  informed  of  what  we 
must  do  to  meet  those  requirements  currently  in 
place. 

Patient  confidentiality  is  an  area  of  continu- 
ing efforts  as  we  try  to  keep  abreast  of  legal  re- 
quirements, while  protecting  what  our  patients 
confide  in  us  from  unnecessary  release  to  third 
parties.  We  must  be  the  voice  for  our  patients  in 
every  way  possible. 

One  area  which  requires  constant  vigil  is  the 
defense  of  the  "cap"  on  malpractice  claims  and 
making  sure  that  the  Patient's  Compensation 
Fund  stays  solvent  but  does  not  cost  more  than 
is  necessary.  The  actuariarly  sound  level  requires 
consultation  with  experts.  The  fund  is  vitally 
important  to  all  of  us.  We  probably  save  more 
on  our  insurance  premiums  than  our  Medical 
Society  dues  cost  us. 

All  of  your  individual  areas  of  concern  are 
of  concern  to  your  Louisiana  State  Medical  Soci- 
ety. If  something  bothers  you,  it  probably  both- 


J La  State  Med  Soc  VOL  152  March  2000  1 01 


ers  others,  too.  We  are  structured  to  represent 
all  areas  of  Louisiana  through  our  district  coun- 
cilors, as  well  as  by  our  general  officers  elected 
by  the  House  of  Delegates.  We  seek  input  from 
our  state  specialty  societies  through  their  com- 
mittee whose  members  are  appointed  by  each 
society  themself.  Thus,  you  have  multiple  chan- 
nels for  possible  two-way  communication. 

On  nationwide  issues,  we  have  an  LSMS 
Committee  on  Federal  Legislation,  constantly 
following  the  latest  from  Capitol  Hill  and  call- 
ing for  your  action  as  needed. 

We  need  your  help  to  inform  your  fellow 
physicians  of  what  we  are  trying  to  accomplish 
in  all  areas  of  concern  to  Organized  Medicine, 
only  a few  of  which  are  listed  here.  And  we  need 
your  support  and  involvement  in  accomplish- 
ing our  goals  on  behalf  of  you  and  your  patients. 

The  LSMS  is  your  Society.  Let  your  officers 
know  what  you  are  thinking. 


102  J La  State  Med  Soc  VOL  152  March  2000 


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ECG  of  th  5 Month 


Appearances  are  Deceiving 

Jorge  I.  Martinez-Lopez,  MD 


The  rhythm  strips  shown  below,  leads  II  and  V2,  belong  to  a 60-year-old  man.  They  were 
recorded  simultaneously  during  a low-level,  treadmill  exercise  test. 


What  is  your  diagnosis? 
Elucidation  begins  on  page  105. 


104  J La  State  Med  Soc  VOL  1 52  March  2000 


4 "h 


ECG  of  the  Month 
Presentation  is  on  page  104. 

DIAGNOSIS  - Trigeminal  rhythm 

The  most  obvious  abnormality  found  in  the 
tracing  is  trigeminal  rhythm,  defined  as  a 
repetitive  pattern  of  three  relatively  closely 
spaced  impulses,  usually  followed  by  a longer 
interval;  the  third  impulse  ordinarily  is  a 
premature  impulse,  but  not  always.  Because  the 
term  "trigeminal  rhythm"  (TR)  is  strictly 
descriptive,  its  cause  must  be  elucidated. 

Before  searching  for  the  mechanism 
responsible  for  TR,  it  is  important  to  obtain 
additional  information  from  the  tracing.  First  is 
the  determination  of  the  basic  cardiac  rhythm: 
it  is  sinus,  at  a rate  of  100  times  a minute,  with 
normal  P waves  in  front  of  every  narrow  QRS 
(N-QRS)  complex.  Both  AV  and  intraventricular 
conduction  are  normal,  as  evidenced  by  the 
normal  length  of  the  PR  and  QRS  intervals, 
respectively.  T waves  are  diphasic  to  inverted 
in  lead  II,  and  flat  in  lead  V . The  QT  interval  is 
normal. 

It  is  now  appropriate  to  return  to  the  primary 
question:  the  mechanism  responsible  for  TR.  The 
major  finding  is  the  intermittent  and  repetitive 
appearance  of  wide  QRS  (W-QRS)  complexes 
after  the  second  N-QRS  of  each  trio.  Features  of 
these  W-QRS  complexes  include  the  following: 
First,  they  show  left  axis  deviation  in  lead  II. 
Second,  in  lead  V2,  a right  bundle  branch  block- 
like pattern  is  present,  with  the  so-called  "left 
rabbit  ear"  taller  than  the  right  one.  Third,  each 
W-QRS  keeps  a fixed  coupling  interval  with  the 
N-QRS  that  precedes  it.  Fourth,  a pause  follows 
every  W-QRS,  then  the  next  sinus  cycle  surfaces. 
Last,  W-QRS  complexes  display  expected 
secondary  ST  segment  and  T-wave  abnorm- 
alities, sloping  away  from  the  direction  in  which 
the  W-QRS  points. 

Given  the  above  findings,  the  mechanism  re- 
sponsible for  the  TR,  at  first  glance,  would  ap- 
pear to  be  premature  ventricular  impulses  (PVIs) 
recurring  in  trigeminy.  But  first  glances  are  not 
always  correct!  Closer  inspection  reveals  that 


the  T waves  which  precede  the  W-QRS  com- 
plexes have  a sharp,  positive,  terminal  deflec- 
tion not  found  in  any  of  the  T waves  of  the  first 
sinus  cycle.  This  deflection,  clearly  evident  in 
both  rhythm  strips,  represents  atrial  electrical  ac- 
tivity. The  morphology  of  this  P wave  (P’)  is  dif- 
ferent from  that  of  the  sinus  P,  and  the  P-P’  in- 
terval is  shorter  than  the  regular  P-P  interval. 
Accordingly,  the  P’  wave  represents  a premature 
atrial  impulse,  and  it  is  followed  by  a W-QRS. 

Premature  atrial  impulses  (PAIs)  are  usually 
followed  by  N-QRS  complexes.  Not  un- 
commonly, however,  the  QRS  that  follows  a PAI 
may  be  abnormally  wide,  because  of  either 
coexisting  bundle  branch  block  or  aberrant 
ventricular  conduction  (AVC).  If  bundle  branch 
block  coexists,  QRS  complexes  before  and  after 
the  PAI  will  also  be  wide  and  display  a 
morphology  that  is  identical  to  the  W-QRS 
occasioned  by  the  PAI. 

On  the  other  hand,  when  W-QRS  complexes 
are  intermittently  present,  as  in  the  current 
tracing,  it  is  not  always  easy  to  differentiate  PVIs 
from  PAIs  with  AVC.  The  AVC  found  with  some 
PAIs  is  not  due  to  organic  disease  of  the 
intraventricular  conduction  system.  It  occurs 
when  the  PAI  encounters  partial  or  complete 
refractoriness  downstream,  in  one  of  the  bundle 
branches.  Because  the  refractory  period  of  the 
right  bundle  branch  is  ordinarily  longer  than  that 
of  the  left  bundle  branch,  it  is  the  right  bundle 
branch  which  is  most  often  refractory  when  the 
PAI  arrives  at  this  juncture.  Superficially,  the 
aberrantly  conducted  PAI  resembles  a PVI 
originating  in  the  left  ventricle.  In  contrast  to  the 
configuration  of  the  W-QRS  in  left  ventricular 
PVIs,  the  W-QRS  due  to  AVC  in  PAIs  usually 
shows  a "classic"  right  bundle  branch  block, 
triphasic  (usually  rsR’)  morphology  in  Vr  The 
strip  shown  here  is  exceptional  because  the  W- 
QRS  morphology  in  V,  favors  the  diagnosis  of 
PVI.  However,  the  distinction  between  PVIs  and 
PAIs  with  AVC  cannot  be  made  on  the  basis  of 
the  appearance  of  the  W-QRS:  appearances  are 
deceiving!  Therefore,  had  P’  waves  not  been 
searched  for,  found,  and  correctly  identified,  an 
incorrect  ECG  diagnosis  of  "PVIs  in  trigeminal 


J La  State  Med  Soc  VOL  152  March  2000  1 05 


rhythm"  would  have  been  made. 

The  deviation  of  the  W-QRS  in  the  frontal 
axis  (lead  II)  also  indicates  that  the  PAIs  not  only 
encountered  refractoriness  in  the  right  bundle 
branch  but  also  in  the  anterior  fascicle  of  the  left 
bundle  branch. 

It  is  typical  for  PAIs  to  be  followed  by  a 
pause.  Usually,  PAIs  successfully  penetrate  the 
SA  node,  discharge  it  prematurely,  and  reset  its 
cycle  of  spontaneous,  automatic  impulse 
formation.  The  pause  occasioned  by  these  PAIs 
is  usually  equal  to  or  slightly  longer  than  the 
basic  P-P  interval,  and  results  in  a so-called 
incomplete  compensatory  pause.  This  contrasts 
with  PVIs,  where  fully  compensatory  pauses  are 
the  rule. 

Finding  that  fixed  coupling  intervals  exist 
between  PAIs  and  the  N-QRS  complexes  that 


precede  them  is  indirect  ECG  evidence  that  the 
most  likely  electrophysiologic  mechanism 
responsible  for  the  PAIs  is  reentry. 

The  presence  of  PAIs  with  AVC,  in  itself,  is  not 
an  ECG  marker  for  underlying  cardiac  disease;  there 
are  many  potential  non-cardiac  causes.  In  the  man- 
agement of  these  patients,  it  is  imperative  to  identify 
the  arrhythmia  correctly,  to  establish  the  presence  or 
absence  of  underlying  heart  disease,  and  to  determine 
whether  or  not  treatment  is  necessary.  In  some  pa- 
tients, modification  or  correction  of  the  underlying 
cause(s)  is  all  that  may  be  necessary.  Others  may  need 
pharmacologic  suppression  of  PAIs,  especially  when 
symptoms  are  present  or  when  PAIs  trigger  frequent 
episodes  of  either  non-sustained  or  sustained  su- 
praventricular tachyarrhytmias. 


Dr  Martinez-Lopez  is  a specialist  in  cardiovascular 
diseases  affiliated  with  the  Cardiology  Service,  Depart- 
ment of  Medicine,  Texas  Tech  University  Health  Sciences 
Center  and  Thomason  General  Hospital  in  El  Paso,  Texas. 


106  J La  State  Med  Soc  VOL  152  March  2000 


Otolaryngology/ 

Head  and 

«tmP «!— 


The  Otologic  Manifestations  of  Barotrauma 

James  P.  Lacey,  MD,  MPH  and  Ronald  G.  Amedee,  MD 


Barotrauma  is  defined  as  an  injury  due  to  pressure  differences  between  atmospheric 
and  intratympanic  pressures.  Human  beings  are  well  suited  to  operate  within  an 
environment  involving  small  alterations  in  atmospheric  pressure.  Man's  persistence 
in  operating  outside  this  environment  leads  to  exposure  to  large  pressure  differentials 
with  resulting  trauma.  External,  middle,  and  inner  ear  structures  can  all  be  injured 
due  to  alterations  in  pressure.  The  increase  in  popularity  of  sport  diving  and  aviation 
travel  has  led  to  an  increase  in  the  number  of  otologic  injuries  caused  by  barotrauma. 
The  physics,  pathophysiology,  symptoms,  and  treatment  of  barotrauma  are  presented. 


The  organs  of  hearing  and  balance  are 
well  suited  to  man's  intended  environ- 
ment which  involves  small  alterations 
in  atmospheric  pressure.  Man's  persistence  in 
operating  outside  this  environment  has  led  to 
alterations  in  the  function  of  and  injuries  to  these 
organs.  Exposure  to  both  undersea  and  aero- 
space environments  are  increasing  rapidly.  The 
greater  exposure  to  scuba  diving  and  air  travel 
has  led  to  increases  in  such  injuries.  Injuries 
caused  by  these  alterations  in  atmospheric  pres- 
sure are  known  as  barotrauma.  While  barotrauma 
can  occur  in  any  air-filled  cavity  in  the  body,  this 
article  will  address  only  those  injuries  related  to 
the  ear. 


REVIEW  OF  PHYSICS 

A complete  review  of  the  physics  of  diving  and 
aviation  is  beyond  the  scope  of  this  article.  A per- 
son at  sea  level  is  constantly  exposed  to  an  am- 
bient pressure  caused  by  the  mass  of  the  earth's 
atmosphere.  This  absolute  pressure  measures  1 
atmosphere  (atm).  One  atmosphere  is  a unit  of 
measurement  equal  to  a pressure  of  14.7  lbs/ in2 
or  760  mm  Hg.  A distinction  must  be  made  be- 
tween gauge  pressure  and  absolute  pressure.  At 
sea  level  the  atmospheric  pressure  is  1 atm  while 
the  gauge  pressure  reads  zero. 

Pascal's  principle  states  that  fluids  are  virtu- 
ally incompressible  at  most  operating  pressures 


J La  State  Med  Soc  VOL  152  March  2000  107 


and  that  external  pressures  are  equally  applied 
throughout  all  body  fluid  compartments.  Two 
gas  laws,  Boyle's  Law  and  Henry's  Law,  pertain 
to  barotrauma.  The  effects  of  pressure  differences 
on  gas  containing  spaces  must  follow  Boyle's 
Law  in  order  to  avoid  barotrauma.  Boyle's  Law 
states  that  with  a constant  temperature,  the 
change  in  volume  is  inversely  proportional  to 
the  absolute  pressure.  Expressed  mathematically 
this  law  is  V = k/P,  where  P indicates  pressure; 
V indicates  volume;  and  k is  a constant.  There- 
fore, as  one  descends  in  altitude  or  depth,  the 
pressure  exerted  on  a body  rises.  Alternatively, 
as  one  ascends  the  pressure  exerted  upon  a body 
decreases.  The  degree  of  rise  or  fall  is  specific 
for  each  particular  medium.  During  descent  in 
sea  water,  pressure  exerted  on  a body  will  double 
every  33  feet.  Descent  to  33  feet  equates  to  an 
absolute  pressure  of  2 atmospheres  or  a gauge 
pressure  of  1 atmosphere.  One  liter  of  gas  at  sea 
level  will  become  1/2  liter  at  33  ft,  1 / 4 liter  at  66 
ft,  and  1/8  liter  at  99  ft.  In  aeronautics,  however, 
the  maximum  pressure  differential  is  only  1 at- 
mosphere. At  18,000  ft  the  pressure  is  one  half 
that  at  sea  level.  At  34,000  ft  the  pressure  is  one 
quarter,  and  at  48,000  ft  the  pressure  is  one 
eighth.1  Changes  in  pressure  near  sea  level  are 
much  greater  than  at  higher  altitudes  and  deeper 
depths.  Therefore,  both  shallow  water  dives  and 
low  altitude  flights  are  at  much  greater  risk  of 
producing  barotrauma. 

Henry's  Law  of  Dissolved  Gases  states  that 
the  amount  of  gas  that  dissolves  in  a liquid  at  a 
given  temperature  is  directly  proportional  to  the 
partial  pressure  of  that  gas  in  contact  with  the 
liquid  and  the  solubility  coefficient  of  the  gas  in 
the  particular  liquid.  Exposure  to  higher  pres- 
sures in  diving  will  result  in  increased  amounts 
of  nitrogen  (with  compressed  air  diving)  or  he- 
lium (with  heliox  diving)  to  become  dissolved 
in  body  tissues  and  fluids.  During  ascent  these 
gases  will  come  out  of  solution.  Ideally  this  will 
occur  in  the  lungs  and  the  excess  gases  can  be 
exhaled.  However,  if  the  ascent  becomes  too 
rapid,  gas  bubbles  may  form  in  tissues  and  body 
fluids  leading  to  decompression  sickness.  This 


law  also  applies  to  the  carbonation  of  soda.  Car- 
bon dioxide  is  pumped  under  pressure  into  a 
soda  can  and  will  become  dissolved  in  the  liq- 
uid. The  carbon  dioxide  comes  out  of  solution 
when  the  pressure  is  released  by  opening  of  the 
can. 

PATHOPHYSIOLOGY 

When  a person  ascends,  the  pressure  exerted  on 
the  body  is  reduced  and  the  volume  of  gas  in  a 
body  cavity  expands.  In  the  middle  ear  this  ex- 
pansion will  push  the  tympanic  membrane  lat- 
erally. Further  ascent  will  cause  an  opening  of 
the  normally  closed  eustachian  tube  and  an 
equalization  of  the  middle  ear  space  will  occur. 
This  is  usually  a reliable  phenomenon  and  thus 
barotrauma  on  ascent  is  infrequent.  During  de- 
scent, the  pressure  exerted  on  a body  increases 
and  the  volume  decreases.  Failure  and  delay  of 
the  eustachian  tube  to  open  will  "lock"  the  tube 
by  causing  collapse  of  the  flexible  nasopharyn- 
geal ostium  and  will  predispose  to  barotrauma. 

Opening  of  the  tube  is  primarily  due  to  con- 
traction of  the  levator  veli  palatini  muscle.  The 
tensor  veli  palatini  and  salpingopharyngeus 
muscles  also  help  open  the  eustachian  tube. 

Tubal  lumen  size  and  muscle  function  vary 
among  individuals.  Thus,  individuals  differ  in 
their  ability  to  equalize  pressure.  On  descent,  the 
eustachian  tube  must  stay  open  long  enough  for 
pressure  to  equalize.  Any  inflammation  or 
edema  of  the  tubal  mucosa,  usually  caused  by 
nasal  inflammatory  disease,  will  affect  the 
opening  time  of  the  eustachian  tube.  Critical 
opening  times  of  0.1  to  0.9  second  are  described 
in  the  literature.2,3  Slow  or  short  eustachian  tube 
opening  times  will  predispose  to  barotrauma. 
The  severity  of  the  barotrauma  is  related  to  the 
speed  of  descent  and  rate  of  pressure  increase. 

There  are  several  maneuvers  that  will  help 
equalize  middle  ear  pressures  during  descent. 
The  modified  Valsalva  maneuver  is  performed 
with  controlled  expiration  with  lips  closed  and 
digital  compression  of  the  nares.  The  Frenzel 
technique  is  performed  by  closing  the  glottis, 
mouth,  and  nose  while  contracting  the  muscles 


108  J La  State  Med  Soc  VOL  152  March  2000 


of  the  floor  of  mouth  and  the  superior  constric- 
tor muscles.  This  technique  is  the  only  one  that 
uses  the  tensor  veli  palatini  muscle  to  open  the 
eustachian  tube.  It  allows  opening  of  the  eusta- 
chian  tube  with  less  pressure,  6 mm  Hg  com- 
pared to  33  mm  Hg  for  the  Valsalva  maneuver. 
The  Toynbee  method  results  in  an  increased  na- 
sopharyngeal pressure  followed  immediately  by 
a negative  pressure.  The  patient  accomplishes 
this  by  swallowing  with  an  occluded  nose. 

If  a diver  descends  and  is  unable  to  clear  his 
ears,  the  mucosa  of  the  middle  ear  and  eusta- 
chian tube  becomes  congested.  This  results  in  a 
net  negative  pressure  inside  the  middle  ear  cav- 
ity. The  resulting  pressure  differential  causes  the 
tympanic  membrane  and  round  window  to 
bulge  inward  to  satisfy  Boyle's  Law.  The  diver 
notices  pain,  pressure,  and  a conductive  hear- 
ing loss.  If  the  diver  continues  to  descend  the 
negative  pressure  in  the  middle  ear  will  cause 
the  eustachian  tube  to  lock.  The  increased  nega- 
tive pressure  will  cause  submucosal  or  mucosal 
hemorrhage.  This  can  also  be  accompanied  by 
transudate  or  bleeding  into  the  middle  ear  space. 
As  the  diver  continues  to  descend,  the  middle 
ear  negative  pressure  continues  to  increase  and, 
if  this  pressure  differential  is  not  relieved,  the 
tympanic  membrane  will  eventually  rupture. 

If  the  diver  attempts  a forceful  valsalva  in  an 
attempt  to  equalize  middle  ear  pressure,  this 
may  result  in  round  window  rupture  and  inner 
ear  injury.  The  valsalva  maneuver  causes  an  in- 
crease in  CSF  pressure  which  is  transmitted  to 
the  endolymphatic  sac  and  may  cause  labyrin- 
thine window  rupture.  In  experiments  per- 
formed on  cats,  a pressure  differential  of  120  to 
300  mm  Hg  will  result  in  round  window  rup- 
ture.4 

Middle  ear  barotitis  has  several  physical 
manifestations:  mucosal  hemorrhage,  mucosal 
edema,  serous  and  hemorrhagic  effusions,  and 
polymorphonuclear  infiltration.  Ultimately,  rup- 
ture of  the  tympanic  membrane  is  the  end  point 
of  barotrauma.  Tympanic  membrane  rupture  oc- 
curs most  commonly  in  the  anterior  portion  over 
the  middle  ear  orifice  of  the  eustachian  tube. 
Tympanic  membrane  rupture  occurs  at  differ- 


entials of  100  to  400  mm  Hg  which  is  equivalent 
to  depths  of  4.3  to  17.4  ft.5  In  addition,  large  pres- 
sure differentials  of  rapid  onset  may  lead  to  ex- 
plosive tearing  of  the  annulus  from  the  tympanic 
sulcus. 

Middle  ear  barotrauma  is  more  frequent 
while  diving  than  while  flying.  Passenger  air- 
craft are  pressurized  to  8000  ft  when  at  cruising 
altitudes.  The  barometric  pressure  at  8000  ft  is 
564  mm  Hg.  Thus,  when  descending,  the  patient 
is  subjected  to  a change  in  pressure  from  564  mm 
Hg  to  760  mm  Hg.  This  is  significant  because 
the  resulting  pressure  differential  of  196  mm  Hg 
is  more  than  enough  to  cause  rupture  if  middle 
ear  pressures  are  not  equalized.1 

TREATMENT 

The  best  treatment  for  middle  ear  barotrauma  is 
prevention.  There  are  several  predisposing  fac- 
tors that  may  increase  the  risk  of  barotitis  and 
these  include  frequent  otitis,  otorrhea,  prior  oto- 
logic surgery,  cholesteatoma,  upper  respiratory 
tract  infection  (acute  or  chronic),  or  sinusitis 
(acute  or  chronic).  Pre-dive  or  pre-flight  treat- 
ment using  topical  or  systemic  antihistamines 
or  decongestants  can  help  reduce  the  risk  of  ba- 
rotitis. Frequent  ear  clearing  during  descent  will 
help  prevent  a large  pressure  differential  and  the 
production  of  mucosal  edema.  In  addition,  slow 
rates  of  descent  help  reduce  the  risk  of 
barotrauma.  Persons  will  often  use  excessive  and 
vigorous  Valsalva  maneuvers  to  attempt  middle 
ear  equalization  once  a pressure  differential  oc- 
curs. However,  if  the  pressure  differential  is  ex- 
cessive this  maneuver  does  not  result  in  middle 
ear  equalization  but  may  lead  to  labyrinthine 
window  rupture  and  inner  ear  injuries. 

When  the  patient  presents  to  the  clinic  or  to 
the  emergency  room,  the  examiner  must  rule  out 
inner  ear  pathology.  The  signs  and  symptoms 
that  should  be  elucidated  are  tinnitus,  vertigo, 
nystagmus,  and  sensorineural  hearing  loss.  A pa- 
tient with  middle  ear  barotrauma  will  fall  into 
several  distinct  categories.  The  patient  will 
present  with  otalgia,  aural  fullness,  otorrhea,  or 
subjective  hearing  loss.  He  may  have  otoscopic 


J La  State  Med  Soc  VOL  152  March  2000  109 


findings  of  tympanic  membrane  retraction,  or 
serous  or  hemorrhagic  effusion.  If  the  patient  is 
without  tympanic  membrane  perforation,  topi- 
cal nasal  decongestants  and  systemic  antihista- 
mines may  be  prescribed.  The  patient  should 
also  be  advised  to  avoid  pressure  changes  for  5 
to  10  days. 

The  treatment  is  slightly  different  if  a patient 
has  a tympanic  membrane  perforation.  Most 
tympanic  membrane  perforations  will  heal  spon- 
taneously. The  removal  of  contaminated  water, 
blood,  or  any  other  debris  from  the  external  au- 
ditory canal  will  help  prevent  a secondary  in- 
fection. Most  clinicians  would  prescribe  otic 
drops,  especially  if  the  injury  occurred  while 
diving.  Before  prescribing  otic  drops,  however, 
be  aware  of  the  possibility  of  labyrinthine  win- 
dow rupture.  Broad  spectrum  antibiotics  may 
be  warranted  to  prevent  secondary  infection  es- 
pecially if  diving  in  contaminated  water. 

External  auditory  canal  barotrauma  may  also 
be  seen  during  diving.  Occurring  mostly  dur- 
ing descent,  a marked  negative  pressure  in  the 
external  auditory  canal  is  created  by  an  object 
blocking  the  external  auditory  canal  from  the 
water.  Cerumen,  foreign  bodies,  diving  hoods, 
solid  ear  plugs,  or  hydrophones  have  all  been 
implicated  in  the  production  of  external  audi- 
tory canal  barotrauma.  The  negative  pressure  in 
the  external  auditory  canal  will  produce  hem- 
orrhagic swelling  with  petechial  hemorrhage, 
blood  filled  blebs  of  skin,  or  gross  blood  in  the 
external  auditory  canal.  Treatment  of  this  con- 
dition is  the  same  as  for  otitis  externa. 

The  inner  ear  structures  are  not  immune  to 
the  effects  of  pressure.  Related  injuries  include 
inner  ear  barotrauma,  inner  ear  decompression 
sickness,  or  inner  ear  injuries  due  to  high  back- 
ground noise  during  diving  conditions.  The 
signs  and  symptoms  of  inner  ear  barotrauma  are 
persistent  vertigo,  sensorineural  hearing  loss,  or 
tinnitus.  The  sensorineural  hearing  loss  is  usu- 
ally a high  frequency  loss  in  the  4-8  kHz  range. 
A key  element  in  the  history  is  whether  or  not 
decompression  sickness  is  likely.  This  is  impor- 
tant because  the  treatment  for  a patient  with  in- 


ner ear  decompression  sickness  is  entirely  dif- 
ferent than  for  a patient  with  only  inner  ear 
barotrauma. 

Often  the  inner  ear  injury  will  result  in  a peri- 
lymphatic fistula  (PLF)  which  may  require  sur- 
gical treatment.  There  are  proponents  of  both 
early  surgical  exploration  or  conservative  treat- 
ment for  the  perilymphatic  fistula.6  7 By  diagnos- 
ing and  treating  a perilymphatic  fistula  early,  one 
may  prevent  or  minimize  permanent  labyrinth 
dysfunction.  Most  surgeons  agree  that  surgery 
should  not  be  delayed  in  patients  with  hearing 
loss.  The  clinicians  that  adopt  a " watch  and  wait" 
approach  argue  that  diagnosis  is  difficult,  even 
during  surgery  and  that  most  fistulas  will  heal 
spontaneously.  The  conservative  therapy  in- 
cludes strict  bed  rest  with  the  head  of  the  bed 
elevated  to  30°  to  45°,  the  use  of  stool  softeners, 
and  no  straining  on  bowel  movements.  Any 
worsening  of  symptoms  should  necessitate  sur- 
gical intervention. 

If  a diver  develops  hearing  loss,  tinnitus, 
vertigo,  nausea,  or  vomiting  during  or  shortly 
after  a dive  in  which  decompression  sickness  is 
possible,  then  a diagnosis  of  inner  ear 
decompression  sickness  must  be  assumed  and 
this  is  a medical  emergency.  Severe  neurologic 
damage  may  occur  if  not  treated  promptly. 
Classic  decompression  sickness  signs  and 
symptoms  can  be  divided  into  two  types.  Type  I 
symptoms  involve  skin  itching  and  bone,  joint, 
or  muscle  pain.  Type  II  symptoms  include 
sensory  or  motor  deficits,  vision  changes,  or  loss 
of  bowel  or  bladder  control.  Treatment  involves 
prompt  usage  of  a recompression  chamber  to 
reduce  gas  bubble  size.  In  addition,  hyperbaric 
oxygen  is  often  felt  to  reverse  local  tissue  anoxia 
and  prevent  further  damage. 

CONCLUSIONS 

Although  the  incidence  of  otologic  injuries  from 
barotrauma  is  unknown,  it  should  be  considered 
in  the  differential  diagnosis  of  patients  present- 
ing to  clinics  or  emergency  rooms  with  recent 
histories  of  airline  travel  or  SCUBA  diving.  A 


110  J La  State  Med  Soc  VOL  152  March  2000 


high  index  of  suspicion  and  prompt  referral  to 
an  otolaryngologist  is  often  necessary  for  treat- 
ment. However,  if  inner  ear  decompression  sick- 
ness is  suspected,  the  patient  should  be  imme- 
diately transported  to  a facility  with  a recom- 
pression chamber  for  definitive  treatment. 

REFERENCES 

1.  Farmer  JC,  Gillespie  CA.  Otologic  medicine  and 
surgery  of  exposures  to  aerospace,  diving,  and 
compressed  gases.  In:  Alberti  PW,  Ruben  RJ  (editors). 
Otologic  Medicine  and  Surgery.  New  York:  Churchill 
Livingstone;  1988:1753-1802. 

2.  Perlman  HB.  Observations  on  eustachian  tube.  Arch 
Otolaryngol  1951;53,  370. 

3.  Miller  GF.  Eustachian  tubal  function  in  normal  and 
diseased  ears.  Arch  Otolaryngol  1965;81,  41. 

4.  Harker  L,  Norante  J,  Rzu  J.  Experimental  rupture  of 
the  round  window  membrane.  Trans  Am  Acad 
Ophthalmol  Otolaryngol  1974;78:448. 

5.  Keller  AP.  A study  of  the  relationship  of  air  pressures 
to  myringopuncture.  Laryngoscope  1958;68:2015. 

6.  Goodhill  V.  Letter  to  the  Editor:  Inner  ear  barotrauma. 
Arch  Otolaryngol  1972;95:558. 

7.  Singleton  GT,  Karlan  MC,  Post  KN.  Perilymphatic 
fistulas.  Diagnostic  criteria  and  therapy.  Ann  Otol 
Rhinol  Laryngol  1978;87:797. 


Dr  Lacey  is  a resident  physician  at  the 
Department  of  Otolaryngology,  Head  and  Neck  Surgery, 
Tulane  University  School  of  Medicine, 
New  Orleans,  Louisiana. 


GACHASSIN 

L A W • F I R M 

Devoted  to  the  Representation  and  Counseling 
of  the  Health  Care  Industry 

The  Gachassin  Law  Firm  provides  quality,  cost- 
effective  legal  services  to  diverse  clients  in  the 
health  care  industry.  Our  attorneys  are  experienced 
in  transactional  and  corporate  matters,  managed 
care  contracting  and  issues,  physician  practice 
management  organizations,  Medicare  and 
Medicaid  reimbursement  issues,  fraud  and  abuse 
and  Stark  compliance,  regulatory  and  legislative 
issues,  medical  malpractice  defense  and  risk 
management. 

Nicholas  Gachassin,  Jr.  Nicholas  Gachassin,  III 

Susan  Severance  Richard  MacMillan 

T.  Rose  Young  Thomas  H.  Morrow 

Julie  Hoffpauir 

1026  St.  John  Street,  Lafayette,  Louisiana  70501 
Telephone:  (337)  235-4576  Fax:  (337)  235-5003 
E-Mail:  gh@gachassin.com 
www.gachassin.com 


Dr  Amedee  is  Professor  and  Chairman  at  the 
Department  of  Otolaryngology,  Head  and  Neck  Surgery, 
Tulane  University  School  of  Medicine, 
New  Orleans,  Louisiana. 


J La  State  Med  Soc  VOL  152  March  2000  111 


' . iv  Case  o e Month 

I- — ■ 


Abdominal  Mass 

Sanjay  M.  Patel,  MD;  Janis  Letourneau,  MD;  and  Harold  Neitzschman,  MD 


A 13-year-old  black  girl  presented  with  a 2-month  history  of  abdominal  distension,  pain,  and 
constipation.  Physical  examination  revealed  a non-tender  but  distended  abdomen. 


Figure  1.  Plain  AP  radiograph  of  the  abdomen. 


Figure  2.  Axial  CT  scan  of  the  abdomen 


What  is  your  diagnosis? 
Elucidation  is  on  page  113. 


112  J La  State  Med  Soc  VOL  152  March  2000 


Figures  3A  and  3B.  Coronal  T1  and  T2  weighted  MRI 
of  the  abdomen. 


Radiology  Case  of  the  Month 
Case  Presentation  is  on  page  112. 

RADIOLOGIC  DIAGNOSIS  - Bilateral 
ovarian  cystic  teratoma 

PATHOLOGIC  DIAGNOSIS  - Same 

INTERPRETATION  OF  IMAGES 

An  abdominal  radiograph  (Figure  1)  shows 
calcifications  (arrow)  in  the  left  abdomen. 
There  is  displacement  of  the  normal  bowel  gas 
pattern  from  the  mid  abdomen.  Computed 
tomography  (Figure  2)  shows  a well- 
circumscribed,  mixed,  predominantly  cystic 
and  solid  mass  on  the  left  side  of  the  abdomen. 
Between  the  solid  and  cystic  component  is  a 
fat  density  area  (straight  arrow)  with  a focus 
of  calcification  (curved  arrow).  A unilocular 
cystic  structure  is  seen  on  the  right  side  of  the 
abdomen.  Coronal  T1  and  T2  weighted  images 
(Figures  3 A and  3B)  demonstrate  two  cystic 
lesions  (arrows)  arising  from  the  pelvis. 

DISCUSSION 

Ovarian  neoplasms,  overall,  are  uncommon  in 
children.1  The  most  common  ovarian  tumor  in 
children  is  a teratoma.2  The  ovary  is  second 
only  to  the  sacrococcygeal  region  as  the  site  of 
origin  of  teratomas.3  Most  ovarian  teratomas 
occur  in  adolescent  girls. 

Cystic  ovarian  teratomas  are  the  most 
common  variety,  and  are  usually  benign.  They 
are  not  discovered  until  they  grow  large 
enough  to  produce  a palpable  mass  or  twist 
on  their  pedicle  causing  abdominal  pain. 

Although  the  majority  of  ovarian  teratomas 
are  benign,  malignant  teratomas  do  occur.  They 
are  sometimes  accompanied  by  ascites, 
intraperitoneal  extension,  and  metastatic 
disease  to  the  liver.  Teratomas  can  lead  to 
ovarian  torsion. 

Plain  films  of  the  abdomen  may  show  an 
abdominal  or  pelvic  mass.  Calcifications  may 
be  seen  in  two  thirds  of  ovarian  teratomas.  A 
recognizable  tooth  within  the  mass  is  a 
pathognomonic  plain  film  finding.  Ultrasound 


demonstrates  the  pelvic  origin  of  the  mass  and 
characterizes  its  component  (cystic  component 
and  increased  echogenicity  due  to  calcifications 
or  fat).4  CT  examination  shows  soft  tissue, 
calcific,  and  fatty  components.  MRI  also 
identifies  tumor  components  and  helps  stage 
patients  with  malignant  disease. 

REFERENCES 

1.  Lazar  El,  Stolar  CJ.  Evaluation  and  management  of 
pediatric  solid  ovarian  tumors.  Semin  Pediatr  Surg 
1998;7:29-34. 

2.  Moon  E,  Kim  Y,  Thim  H,  et  al.  Coexistent  cystic 
teratoma  of  the  omentum  and  ovary:  report  of  two 
cases.  Abdom  Imag  1997;22:516-518. 

3.  Gonzolo  AE,  Merino  MI,  Ferandez-Teijeiro  A A,  et  al. 
Ovarian  tumors  in  childhood:  apropos  of  a review  of 
cases.  Anales  Espanoles  de  Pediatria  1998;49:491-494. 

4.  Lee  DK,  Kim  SH,  Cho  JY,  et  al.  Ovarian  masses 
appearing  as  solid  masses  on  ultrasound.  J Ultras  Med 
1999;18:141-145. 


Dr  Patel  is  a senior  resident  at  Louisiana  State  University 
Health  Sciences  Center  in  New  Orleans , Louisiana. 

Dr  Letoumeau  is  a professor  of  radiology  and  surgery 

at  Louisiana  State  University 
Health  Sciences  Center  in  New  Orleans,  Louisiana. 

Dr  Neitzschman  is  an  associate  professor  of 
radiology  and  orthopaedics  at  Louisiana  State  University 
Health  Sciences  Center  in  New  Orleans,  New  Orleans. 


J La  State  Med  Soc  VOL  152  March  2000  113 





March  1850  and  1900 

Gustavo  A.  Colon,  MD 


In  the  March  1850  issue  of  the  Journal,  there 
is  an  amazing  article  written  by  Dr  Bennett 
Doller  of  New  Orleans  on  researches  of  the 
natural  history  of  death.  The  purpose  of  this  ar- 
ticle was  to  attempt  to  identify  the  pathological 
anatomy  and  the  causes  of  death  and  its  imme- 
diate antecedents  and  effects,  physical  and  physi- 
ological, in  order  to  identify  at  what  point  death 
occurred  between  the  period  of  "agony"  and  the 
postmortem  examination.  In  1837,  a professor 
Manni  of  the  University  of  Rome  proposed  a 
special  prize  of  about  1500  francs  to  be  awarded 
by  the  French  Academy  for  the  best  work  upon 
the  subject  of  apparent  death  with  the  view  of 
preventing  premature  interment.  He  stated  that 
in  a book  written  by  M Bruhier  titled  Recherches 
Medico-Legales  there  had  been  180  frightful  ex- 


amples of  persons  dissected  before  death,  pa- 
tients falsely  reported  dead,  and  even  those  en- 
tombed alive.  He  gives  several  examples  of  pa- 
tients who  were  presumed  dead,  but  survived. 
One  is  a case  of  Dr  Benjamin  Rush  of  Philadel- 
phia. The  patient  was  a 19-year-old  man  who 
was  infected  with  Yellow  Fever  and  died  with 
the  black  vomit  on  the  fourth  day.  During  the 
apparent  death,  of  4 hours  duration,  the  doctor 
gave  him  some  strong  brandy  every  1/2  hour, 
and  it  was  remarkable  that  the  man  woke  up 
and  subsequently  survived,  and  this  was  wit- 
nessed by  many,  according  to  the  narrative,  in- 
cluding a Virginia  lawyer  with  whom  the  au- 
thor was  well  acquainted.  He  classifies  prema- 
ture burial  as  the  reason  to  wait  3 to  4 days  prior 
to  burial  to  make  sure  the  patient  was  dead  and 


114  J La  State  Med  Soc  VOL  152  March  2000 


not  to  allow  these  individuals  to  be  buried  alive. 
He  said  that  since  1833  there  have  been  approxi- 
mately 94  persons  who  were  improperly  bur- 
ied in  France  and  woke  up  from  the  //lethargy,/. 
He  states  that  35  persons  woke  themselves,  13 
recovered  as  a consequence  of  the  affectionate 
care  from  their  families,  7 as  a consequence  of 
dropping  the  coffins  in  which  they  were  en- 
closed, 9 others  to  wounds  inflicted  by  the 
needle  that  was  being  used  to  sew  their  wind- 
ing sheet  prior  to  burial,  5 to  the  sensation  of 
suffocation  in  their  coffin,  and  19  to  having  had 
their  burial  detained  for  some  unexplained  cir- 
cumstances. One  of  the  most  amazing  resurrec- 
tions was  very  romantic.  Madame  Ronell  died 
in  1810  and  was  buried,  not  in  a vault  but  in  the 
ground.  Her  lover,  a Monsieur  Bossuet  having 
heard  of  her  death  undertook  a long  journey  in 
order  to  get  a lock  of  her  hair.  He  proceeded  to 
the  cemetery,  dug  her  up  at  midnight,  and  found 
her  alive.  She  married  him  and  fled  to  America 
in  order  to  distance  herself  from  her  banker 
husband  who  had  buried  her. 

Now  the  ultimate  test  of  death,  of  course, 
was  decomposition  of  the  body,  but  it  was 
inconvenient  to  wait  for  that  so  it  was  therefore 
conceded  that  the  award  should  be  made 
conscientiously  to  those  who  could  diagnose  the 
immediate  certain  science  of  death.  It  was  felt 
that  the  signs  consisted  in  (1)  the  prolonged 
absence  of  sounds  of  the  heart,  (2)  the 
simultaneous  relaxations  of  the  sphincters,  and 
(3)  the  sinking  of  the  globe  of  the  eyes  with  loss 
of  transparency  of  the  cornea.  These  signs  were 
regarded  as  conclusive.  The  remote  signs  were 
(1)  postmortem  rigidity,  (2)  the  absence  of 
muscular  contractility  with  the  influence  of 
galvanism,  and  (3)  decomposition.  Therefore, 
the  author  states  "the  ultimate  conclusion  was 
a philosophical  one,  but  the  solution  of  the 
problem  of  life  does  not  yet  comprehend  the 
duration  and  termination  of  life,  that  is,  the 
period  when  the  candle  of  life  shall  burn  out, 
when  the  vital  capital  shall  wholly  be  expended. 
Unhappy  will  it  be  for  the  physiologist  if  on 
entering  life  he  shall  then  know  the  very  hour 
of  his  own  death  inscribed  in  specific  time  when 


the  wheels  of  life  at  last  stand  still  like  a clock 
worn  out  with  beating  time.  Happily  for 
mankind,  science  has  not  yet  made  the 
paralyzing  discovery  of  the  time  of  death  but 
lets  us  struggle  to  identify  death  scientifically 
when  it  does  occur." 

In  the  March  1900  issue  of  the  Journal,  there 
is  an  article  which  is  in  keeping  with  the 
discourses  on  diseases  that  are  no  longer  seen 
in  our  century  and  that  we  have  basically 
conquered  in  past  centuries.  Dr  A G LeBeouf  of 
New  Orleans  wrote  the  History  of  Smallpox  and 
this  was  read  before  the  Orleans  Medical  Society. 
It  is  interesting  to  read  his  dissertation. 

"Variola,  from  the  Latin  word  varus , or  the 
diminutive  of  the  word  varus,  which  means 
pimple,  was  used  in  ancient  times  to  designate 
any  skin  infection  with  the  accompaniment  of 
pimples  or  papules  or  pustules.  At  a latter  date, 
it  was  used  only  to  designate  smallpox;  that 
latter  word  came  from  the  word  "pock", 
meaning  a bag  or  sack,  from  the  appearance  of 
its  principal  symptom.  It  was  called  smallpox 
in  contradistinction  to  la  grande  verole,  as  the 
eruption  of  syphilis  was  denominated.  In 
France,  it  was  known  as  la  petite  verole  and 
applied  only  to  smallpox,  though,  for  a long 
period  of  history,  the  two  were  confounded 
together  and  the  diagnosis  of  smallpox  was 
invariably  mixed  with  that  of  measles,  syphilis, 
bubonic  plague,  and  some  other  exanthematous 
diseases.  The  first  physician  who  limited  the 
application  of  the  name  smallpox  to  variola  was 
Constantinus  Africanus.  The  exact  origin  of  this 
most  loathsome  disease  is  shrouded  in  mystery. 
It  seemed  to  have  been  known  in  the  most 
ancient  times,  but  it  was  so  much  confounded 
with  some  of  the  dreadful  plagues  that  visited 
the  remote  periods  of  history  that  we  cannot 
accurately  tell  the  date  of  its  first  appearance. 
Smallpox  is  certainly  not  indigenous  to  Europe, 
and  was  not  known  in  America  prior  to  the 
conquest  of  Mexico  by  Cortez.  It  is  often  said 
that  Hippocrates  and  Celsus  knew  of  it,  but  that 
has  not  been  definitely  proven,  and  in  the 
descriptions  given  by  Galen  we  cannot  recognize 
all  the  features  of  smallpox. 


J La  State  Med  Soc  VOL  152  March  2000  115 


"We  are  certain  at  this  day  that  we  owe  this 
disease  to  China  and  Hindustan,  where  the  over- 
crowded condition  of  the  population  naturally 
increased  the  possibility  of  all  contagious  and 
infectious  diseases.  Moore  dates  the  earliest 
knowledge  of  it  to  1120  be,  but  later  researches 
do  not  support  this  opinion. 

"In  India,  before  the  time  of  Christ,  a goddess 
was  worshipped  whose  friendly  intervention 
was  supposed  to  preserve  the  faithful  from  the 
dreaded  disease.  Historically,  the  first  report  of 
smallpox  was  handed  down  to  us  in  544  by 
Procopius,  who  gave  a description  of  the  disease 
in  his  de  Bello  Persico ; he  described  an  epidemic 
or  scourge  which  took  place  at  Pelusium  and 
which  invaded  Egypt,  Syria,  and  the  whole  of 
Asia.  But  Gregory  considered  that  even  this  is 
more  apt  to  have  been  bubonic  plague  than 
variola,  though  in  Book  II,  Chapter  22,  he 
describes  symptoms  that  could  have  well  been 
smallpox.  The  first  certain  knowledge  we  have 
of  the  disease  we  owe  to  a description  of  a fearful 
scourge  which  took  place  in  ad  581,  given  by 
Gregory  of  Tours.  It  raged  all  through  Southern 
Europe  and  was  distinctly  differentiated  by  the 
chronicler  from  an  epidemic  of  bubonic  plague, 
which  broke  out  the  following  year,  582,  at 
Narbonne.  This  scourge  was  known  as  Lues  cum 
resicis,  pustula  pustula,  or  morb.  dysentericus  cum 
pustulis , in  contradistinction  to  morb.  inguinarius , 
or  bubonic  plague.  In  a narrative  of  one  of  the 
expeditions  of  the  Abyssinians  against  Mecca, 
Gregory  also  refers  to  a breaking  out  among  the 
invading  army,  but  he  clothes  this  description 
with  all  manner  of  superstition,  mystery,  and 
tradition. 

"Still  it  is  to  the  Arabians,  and  especially  to 
Rhazes,  that  we  owe  our  first  exact  knowledge 
of  the  disease.  He  was  a noted  scientist,  born  in 
850.  After  traveling  through  the  far  East  and 
studying  in  Spain,  he  practiced  medicine  in 
Bagdad.  He  wrote  many  works  on  medicine  and 
philosophy,  and  also  a Cyclopedia  on  Medical  Sci- 
ence, and  finally  a Treatise  on  Smallpox  and 
Measles,  which  was  translated  at  Poitiers  in  1556 
by  S Collin.  He  had  a theory  on  the  pathology 
of  the  disease  and  labored  under  the  impression 


that  it  was  due  to  some  fermentative  state  of  the 
blood.  Whatever  may  have  been  his  errors  in  the 
etiology  and  pathology  of  the  disease,  he  gave 
us  such  good  suggestions  for  its  treatment  that 
we  of  the  present  time  could  afford  to  follow 
them.  He  rubbed  his  patients  with  oils  and  salves 
to  prevent  pitting.  This  method  was  evidently 
abused,  for  we  are  told  that  a Bishop  Felix  of 
Nantes  used  a blister  salve  on  his  left  leg  and 
died  of  the  gangrene  resulting  from  it. 
Constantinus  Africanus,  born  in  Carthage  at  the 
beginning  of  the  twelfth  century,  began  by  his 
teaching  and  works  to  educate  Italy  in  medical 
matters  and  raised  science  in  that  country  to  the 
degree  attained  by  the  East  and  Ancient  Greece. 
His  teachings  were  concise,  and,  in  his  descrip- 
tion of  smallpox,  he  followed  the  lines  taught  by 
his  Arabian  predecessors.  Before  the  time  of 
Constantinus,  we  know  very  little  of  the  history 
of  smallpox  in  Europe,  though  it  was  known  to 
have  devastated  whole  regions  at  a time.  Cer- 
tainly, the  frequent  Crusades  must  have  brought 
the  contagion  many  times,  and  then  again  when 
the  Moors  invaded  Spain  they  brought  the 
scourges  of  the  great  East  with  them.  It  was  only 
after  such  momentous  migrations  or  invasions 
that  disease  could  spread  in  those  days.  Because 
of  the  scant  communication  between  countries, 
the  nations  and  their  people  never  met.  A nar- 
row sea  or  a low  range  of  mountains  intercepted 
communication.  It  will  readily  be  understood 
why  the  diseases  of  one  country  were  scarcely 
known  by  another. 

"Variola  entered  England  in  1241,  Sweden  in 
the  middle  of  the  fifteenth  century,  and  Germany 
at  the  end  of  that  century.  It  was  introduced  in 
America  through  Mexico  in  1527,  and  it  rapidly 
overran  the  whole  of  the  Western  Hemisphere. 
It  is  certain  that  it  was  not  known  by  the  North 
American  Indians,  the  early  explorers  never  saw 
the  tell-tale  pock  mark  on  the  red  man's  face. 
Would  not  this  go  to  disprove  the  alleged 
connection  said  to  exist  between  the  Aztec 
civilization  with  that  of  India,  or  to  place  this 
consanguinity  very  far  away  in  the  earliest  times? 
In  America,  the  disease  had  gained  a foothold, 
and  it  continues  its  ravages  periodically  to  our 


116  J La  State  Med  Soc  VOL  152  March  2000 


AS  PRESENTED  TO 
THE  MEMBERSHIP  OF  THE 

Louisiana  State  Medical  Society 


I 


1 998-99  Board  of  Governors 


Leo  L.  Lowentritt,  Jr.,  MD 

C.  Clinton  Lewis,  MD 

Dudley  M.  Stewart,  Jr.,  MD 

Michael  S.  Ellis,  MD 

K.  Barton  Farris,  MD 

Russell  C.  Klein,  MD 

Wallace  H.  Dunlap,  MD 

Charles  D.  Belleau,  MD 

Joshua  E.  Lowentritt,  MD 

Joshua  Patt 

Board  of  Councilors 

Vincent  Culotta,  MD 

Richard  J.  Paddock,  MD 

Barry  G.  Landry,  MD 

William  T.  Hall,  MD,  Chair 

Joseph  Busby,  Jr,  MD 

Lynn  Z.  Tucker,  MD 

R.  Mark  Williams,  MD 

Martin  B.  Tanner,  MD 

Martin  J.  Ducote,  Jr.,  MD 

Marcus  L.  Pittman,  III,  MD 

Alternate  District  Councilors 

Floyd  A.  Buras,  Jr.,  MD 

Tod  Engelhardt,  MD 

Walter  H.  Daniels,  MD 

Robert  Hernandez,  MD 

John  M.  Coats,  MD 

D.  Gerard  Fourrier,  MD 

Aretta  Rathmell,  MD 

William  Elwyn  Lyles,  MD 

Maximo  Lamarche,  MD 

Ralph  Maxwell,  III,  MD 

* Executive  Committee  of  the  Board  of  Governors 

AMA  Delegation 

Delegates 

W.  Juan  Watkins,  MD  • Chair 
Milton  C.  Chapman,  MD 
Michael  S.  Ellis,  MD 
K.  Barton  Farris,  MD 
Jay  M.  Shames,  MD 

Alternates 

Carol  L.  Bayer,  MD 
Lawrence  L.  Braud,  MD 
Wallace  H.  Dunlap,  MD 
Dudley  M.  Stewart,  Jr.,  MD 
Joshua  E.  Lowentritt,  MD  • Resident 


President * 

President-Elect * 

Vice  President* 

Immediate  Past  President* 

Speaker,  House  of  Delegates* 

Vice  Speaker,  House  of  Delegates 

Secretary-Treasurer* 

Chair,  Council  on  Legislation 

Resident  Member 

Medical  Student  Member 


First  District 

. Second  District 
...  Third  District 
Fourth  District* 

Fifth  District 

....  Sixth  District 
Seventh  District 
..Eighth  District 
...Ninth  District 
...  Tenth  District 


First  District 

. Second  District 
...  Third  District 
. Fourth  District 

Fifth  District 

....  Sixth  District 
Seventh  District 
..Eighth  District 
...Ninth  District 
...  Tenth  District 


Young  Physicians  Section 

Victor  Tedesco,  IV,  MD  • Delegate 
James  Baker,  MD  • Alternate 

AMA  Officials 

Donald  Palmisano,  MD  • Board  of  Trustees 

Daniel  H.  "Stormy"  Johnson,  Jr.,  MD  • Past  President,  1997-98 


Supplement  2 VOL  152  March  2000  J La  State  Med  Soc 


Report  of  the  President 


To  say  the  least,  it  has  been  a very  busy  year.  Serving 
as  President  of  the  LSMS  is  a tremendous  challenge 
and  great  honor.  It  has  been  an  unforgettable 
experience  and  I hope  I have  contributed  to  the  future  of 
organized  medicine  in  some  small  way. 

My  objectives  for  the  past  year  were  the  1999 
Legislative  Session,  improved  LSMS  communication, 
grassroots  organization,  increased  membership,  managed 
care  reform,  meeting  with  component  societies,  and 
building  bridges  to  nonmembers  and  minority  medical 
societies.  In  addition,  I focused  on  maintaining  a good 
working  relationship  with  the  Department  of  Insurance 
under  Commissioner  Jim  Brown  and  the  Department  of 
Health  and  Hospitals  under  Secretary  David  Hood. 
Finally,  on  the  federal  level,  I participated  in  the  AMA 
delegation  and  promoted  the  LSMS  and  medicine  in 
Washington. 

To  prepare  for  the  session,  the  LSMS  developed  better 
ways  to  communicate  with  its  members.  Dr.  Benson  Scott 
helped  with  the  initial  development  of  the  LSMS  web  site. 
Subsequently,  the  site  was  further  refined  and  enhanced 
by  our  LSMS  staff. 

Email  is  a relatively  new  and  inexpensive  way  for  the 
LSMS  to  communicate  with  its  members.  We  now  have 
the  capability  to  email  to  more  than  one  thousand 
members.  Obviously,  as  we  receive  additional  email 
addresses,  this  capability  will  improve.  We  implemented 
a system  for  blast  faxes,  which  also  increased 
communication  with  our  members.  Fax  communication 
was  used  extensively  during  the  legislative  session. 

The  LSMS  leadership  now  receives  a monthly 
Executive  Memo  newsletter.  The  Journal  was  improved  and 
the  Journal  Board  continues  to  evaluate  the  direction  in 
which  it  should  go.  As  directed  by  the  House  of  Delegates, 
I submitted  monthly  articles  to  the  Journal  as  the 
President's  Message.  It  is  exciting  to  have  your  own  page 
to  convey  your  thoughts  to  the  entire  membership.  The 
Department  of  Public  Affairs  continues  to  expand  and 
reflect  on  current  information  in  Capsules.  The  Pelican 
campaign  newsletter  was  successfully  used  to  promote 
the  candidacy  of  Dr.  Don  Palmisano  for  AMA  Board  of 
Trusties. 

Our  Department  of  Legal  Affairs  continues  to  expand 
its  efforts  to  respond  to  member  needs.  The  House  of 
Delegates  has  approved  several  new  programs  and  the 
growing  number  of  calls  and  letters  from  members  for 
assistance  has  increased  significantly  the  workload  of  our 
General  Counsel.  This  service  has  become  an  important 
benefit  for  our  members. 

The  continuing  medical  education  accreditation 


program  has  continued  to  expand  its  operations  with  33 
intrastate  providers  currently  accredited  and  is  prepared 
for  the  increased  demand  resulting  from  the  recently 
enacted  statute  requiring  physicians  to  meet  continuing 
education  requirements.  The  LSMS  Educational  and 
Research  Program's  CME  Program  has  the  ability  to 
provide  quality  accredited  CME  to  physicians  throughout 
Louisiana.  The  Program  has  been  jointly  sponsoring 
activities,  especially  with  the  component  medical  societies 
and  state  specialty  societies,  and  expects  to  see  the 
demand  for  this  grow  in  the  coming  year. 

I continued  to  pursue  development  of  the  Specialty 
Society  Committee  (SSC)  under  the  combined  leadership 
of  Dr.  Thomas  Bertuccini  (Chair)  and  Dr.  Wayne  Gravois 
(Vice  Chair).  The  SSC  provided  access  to  many 
nonmembers  as  well  as  to  the  leaders  of  the  Louisiana 
specialty  societies.  This  forum  proved  invaluable  as  a 
source  of  information  and  to  help  resolve  issues  before 
they  became  problems.  It  is  too  late,  and  counter- 
productive, to  debate  our  differences  in  open  legislative 
committee  hearings.  Many  of  the  specialty  societies  served 
as  an  excellent  conduit  for  communication  to  their 
members  to  lobby  the  legislature.  It  is  my  hope  that  the 
SSC  will  continue  to  be  nourished  and  expanded. 

I worked  to  expand  participation  of  the  LSMS  Alliance 
in  our  legislative  efforts.  In  fact,  the  Alliance  was  a great 
help  in  our  legislative  grassroots  initiative  this  year.  Under 
the  aggressive  leadership  of  Karen  Depp,  I see  an 
expanded  and  more  integrated  role  for  the  Alliance.  The 
Alliance  will  resume  their  Annual  Meetings  at  the  same 
time  as  the  LSMS  House  of  Delegates  commencing  in 
October,  2000.  This  should  increase  the  attendance  of  both 
organizations. 


Supplement  3 VOL  152  March  2000  J La  State  Med  Soc 


I strongly  encouraged  a grassroots  initiative  at  the 
component  society  level  and  they  responded.  The 
Louisiana  legislators  related  to  us  that  this  was  the  largest 
outpouring  of  mail  and  communication  from  the  LSMS 
that  they  had  ever  seen.  By  the  middle  of  the  session,  most 
legislators  were  well  aware  of  our  issues.  Without  this 
support,  we  would  never  have  been  so  successful. 

Because  of  the  immense  number  of  bills  introduced 
this  session,  the  LSMS  hired  additional  contract  lobbyists. 
Our  contract  lobbyists,  Harris,  DeVille  and  Associates  and 
former  state  representative  Alphonse  Jackson,  were 
extremely  instrumental  in  our  success  this  session. 
Without  their  experience,  legislative  relationships,  and 
credibility,  we  would  not  have  been  able  to  defeat  such 
issues  as  psychology  prescribing,  physician  assistant 
prescribing,  childhood  immunization  schedule  changes, 
increases  in  the  medical  malpractice  cap  and  unwanted 
changes  to  the  Louisiana  State  Board  of  Medical 
Examiners.  In  addition,  our  contract  lobbyists  also  used 
their  considerable  talents  to  help  the  LSMS  pass  key 
legislation,  such  as  mental  health  parity.  Our  LSMS 
Governmental  Affairs  staff  is  highly  regarded  in  the 
legislature  and  continues  to  do  a tremendous  job  in 
representing  our  interests. 


Dr.  Lowentritt  presides  over  the  April  Board  of 
Governor’s  meeting. 


Our  success  in  the  1999  Regular  Legislative  Session 
was  one  of  the  best  on  record.  Not  one  bill  was  enacted 
into  law,  which  the  LSMS  actively  opposed.  We  defeated 
the  psychologists'  attempt  to  obtain  prescriptive  authority. 
The  physicians'  assistant's  prescriptive  authority  bill  was 
soundly  defeated.  The  hypnotherapists'  attempt  to 
establish  their  own  licensing  board  was  defeated  in 
committee.  A strong  healthcare  coalition  passed  mandated 


health  insurance  coverage  for  13  diagnoses  of  the  most 
severe  mental  illnesses.  This  was  a major  victory  that  had 
been  sought  for  many  years  and  was  vehemently  opposed 
by  business  and  insurance  interests.  Several  attempts  to 
increase  the  medical  malpractice  cap  of  $500,000  were 
defeated.  An  attempt  to  raise  attorney  chairman  fees  to 
$5,000  for  medical  review  panels  failed  to  pass  even  when 
amended  to  $3,000.  Blood  liability  and  prescription  and 
preemption  periods  for  liability  were  passed  reducing 
liability  for  Hepatitis  C prior  to  1992  secondary  to  blood 
transfusion.  We  fought  off  attempts  to  place  a physician 
nominated  by  the  Louisiana  Hospital  Association  and  a 
nonvoting  APRN  on  the  Louisiana  State  Board  of  Medical 
Examiners.  However,  we  did  not  oppose  a provision 
instituting  term  limits  for  the  members  of  the  board.  The 
LSMS  can  now  only  nominate  four,  instead  of  six  of  the 
seven  members  of  the  board.  The  Louisiana  Medical 
Association  will  nominate  two,  and  the  Louisiana 
Academy  of  Family  Practice  will  nominate  one. 
Unfortunately,  we  were  unsuccessful  in  passing  legislation 
to  help  protect  the  Patients  Compensation  Fund  (PCF). 
We  attempted  to  provide  for  reimbursement  schedules 
for  the  payment  of  future  medical  care.  This  could  have 
saved  the  PCF  more  than  $3.7  million  a year.  These  are 
only  a few  of  the  approximately  750  bills  that  affected 
medicine  in  some  way. 

The  Louisiana  Psychiatric  Medical  Association's 
(LPMA)  contract  lobbyist,  Vera  Olds,  worked  diligently 
with  the  LSMS  to  defeat  the  psychology  prescribing  issue. 
After  a five-year  effort,  Ms.  Olds  also  helped  pass  a 
mandate  for  health  insurance  coverage  of  13  diagnoses 
of  severe  mental  illness.  The  coordinated  efforts  of  the 
DGA  staff,  the  LSMS  contract  lobbyists  and  Ms.  Olds  were 
critical  to  our  success  on  these  two  priority  issues. 

I initiated  contact  with  the  Louisiana  Legislative  Black 
Caucus  through  Representative  Israel  Curtis.  I was 
received  warmly  by  Representative  Sherman  Copelin, 
Chairman,  at  a meeting  of  the  Corporate  Roundtable,  an 
organization  founded  by  the  Black  Caucus.  In  fact,  the 
LSMS  has  been  invited,  and  intends  to  join  the  Corporate 
Roundtable.  We  hope  this  will  be  an  enduring  and 
mutually  beneficial  relationship. 

I attended  the  Annual  Meeting  of  the  Louisiana 
Chapter  of  the  American  Association  of  Physicians  from 
India.  This  was  the  first  time  an  LSMS  President  had 
spoken  to  organization.  Dr.  Gupta,  President,  and  their 
members  were  extremely  cordial  and  interested  in  my 
comments.  I hope  their  organization  will  take  advantage 
of  our  invitation  to  be  "official  observers"  at  our  House 
of  Delegates.  I emphasized  that  we  were  all  physicians  in 
the  House  of  Medicine  and  shared  the  same  or  similar 
interests  and  concerns  for  our  patients. 

My  predecessor.  Dr.  Mike  Ellis,  has  continued  his 
contacts  with  the  Louisiana  Medical  Association  (LMA). 
I hope  that  the  LMA  will  also  accept  our  invitation  to  be 
"official  observers"  at  our  House  of  Delegates. 


Supplement  4 VOL  152  March  2000  J La  State  Med  Soc 


Membership  continues  to  be  an  area  of  concern.  I have 
eached  out  to  all  the  component  societies  and  encouraged 
hem  to  be  inventive  and  work  to  both  recruit  new 
nembers  and  to  retain  our  current  membership. 
5hysicians  have  specialty  societies  and  hospitals 
:ompeting  for  their  time  as  well.  Membership  recruitment 
:ontinues  to  be  the  highest  priority  of  our  Department  of 
Membership  and  Finance.  Hopefully  a renewed  emphasis 
vill  be  vigorously  pursued  as  the  future  of  the  LSMS 
lepends  on  reaching  out  to  more  physicians. 

To  reach  new  leaders,  the  LSMS  held  the  second 
annual  Leadership  Conference.  It  was  well  attended  and 
vill  be  expanded  yearly.  Under  the  direction  of  our  new 
nembership  chairman.  Dr.  Eduardo  Rodriguez,  the  first 
Membership  Summit  will  be  held  in  November  with  a 
acilitator  to  encourage  new  ideas.  Hopefully  you  will  see 
esults  in  the  form  of  renewed  interest  in  membership.  If 
he  LSMS  is  to  attract  new  members  and  retain  our  current 
nembers,  we  must  give  value.  Value  is  different  for 
lifferent  group.  The  LSMS  must  think  " outside  the  box" 
o find  ways  to  reach  all  physicians.  We  must  first  identify 
.ouisiana  physicians  and  survey  their  needs.  We  must 
hen  work  to  satisfy  those  needs  and  give  them  value  in 
eturn  for  their  dues. 

Our  legislative  effort  is  central  to  all  physicians'  needs. 
Managed  care  was  a top  priority  this  year.  The  Managed 
Zaie  Liaison  Committee  was  extremely  active  under  the 
killful  direction  of  Dr.  Jay  Shames,  Dr.  Van  Cullotta,  Dr. 
loyd  Bur  as.  Dr.  Mike  Ellis,  and  others.  Many  of  the  House 
>f  Delegates  resolutions  of  last  year  were  incorporated 
nto  bills  and  ultimately  enacted  into  law.  There  is  still 
nuch  work  to  be  done.  We  will  continue  to  work  with 
he  Office  of  Health  Insurance  within  the  Department  of 
nsurance,  to  draft  rules  and  regulations  to  implement 
he  intent  of  these  legislative  instruments. 

Commissioner  Brown  and  his  Deputy  Commissioner, 
Richard  O'Shee,  were  great  to  work  with  this  year.  The 
department  of  Insurance  (DOI)  and  the  LSMS  sponsored 
nany  bills  that  went  on  to  become  law.  All  insurance  sold 
n the  state  must  comply  with  Louisiana  law. 
Requirements  for  entities  making  medical  necessity 
lecisions  were  established.  This  includes  the  right  to  sue 
uch  entities  for  negligent  acts.  We  expect  this  provision 
)f  the  law  to  be  litigated  by  the  insurance  industry.  Timely 
payment  legislation  established  procedures  and  time 
rames  for  the  prompt  payment  of  health  services  by  both 
LMOs  and  health  insurance  plans.  Health  insurance 
)enefit  cards  must  display  the  responsible  party  for  the 
:overage  and  eliminate  confusion  on  what  plans  are 
egulated  and  what  plans  are  exempt  under  federal  law. 
iMOs  must  provide  coverage  for  clinical  trial  treatment 
or  life  threatening  conditions  such  as  cancer. 

The  LSMS  staff  and  its  officers  met  several  times  with 
Secretary  David  Hood  of  the  Department  of  Health  and 
Tospitals  (DHH).  We  have  continued  to  develop  a close 


working  relationship  with  DHH.  With  Secretary  Hood's 
help,  we  were  able  to  initiate  a small  increase  in  fees  for 
three  specific  CPT  codes,  and  maintain  at  least  the  same 
reimbursement  level  for  the  Medicaid  program.  The 
executive  budget  submitted  to  the  legislature  by  the 
Governor  called  for  a cut  to  Medicaid.  DHH  fought  to 
maintain  funding  for  Medicaid  at  its  present  level.  Money 
from  the  tobacco  settlement  was  used  to  maintain  the 
present  funding  level  of  Medicaid.  The  LSMS  will 
continue  its  efforts  to  obtain  increases  for  private 
physician  reimbursement.  Secretary  Hood  is  well  aware 
of  the  low  reimbursement  levels  for  physicians  and  is 
trying  to  find  ways  to  secure  additional  funding  for 
raising  physician  reimbursement. 

We  also  discussed  with  Secretary  Hood  fraud  and 
abuse  detection,  and  the  LSMS  was  assured  that  mistakes 
in  ordinary  coding  were  not  the  primary  target  of  such 
endeavors.  Our  LSMS  attorneys  reviewed  in  detail  the 


DHH  Surveillance  and  Utilization  Review  System 
regulations  and  were  able  to  elicit  significant  changes. 


Dr.  Lowentritt,  Senator  John  Breaux,  and  Beverly  Lowentritt  at 
the  Nathan  Davis  awards  ceremony. 


My  Washington  agenda  was  full  with  three  trips.  We 
visited  all  of  the  members  of  the  Louisiana  congressional 
delegation  or  their  aides  on  our  annual  Washington 
legislative  visit.  The  Department  of  Governmental  Affairs 
prepared  an  excellent  briefing  booklet  for  the  LSMS 
delegation  which  included  Dr.  Clint  Lewis,  Dr.  Bill  Hall, 
Dr.  Keith  Desonier,  Dr.  Bill  Cassidy,  Dr.  Floyd  Buras,  Dr. 
David  Treen,  Dr.  Richard  Paddock,  Dave  Tarver,  Dave 
Kemmerly  and  Susan  D' Antoni.  We  met  with  the  federal 
legislation  division  of  the  AMA  who  briefed  us  on  current 
healthcare  issues  before  our  meetings  with  members  of 
our  congressional  delegation.  Key  issues  focused  on  in 
the  meetings  with  our  delegation  were  fraud  and  abuse. 
Medicare  reform,  and  patients'  rights. 

Mardi  Gras  in  Washington  has  become  an  annual 
event  of  the  LSMS.  It  is  a great  time  to  meet  with  our 


Supplement  5 VOL  152  March  2000  J La  State  Med  Soc 


Louisiana  Delegation  on  an  informal  basis.  Dr.  Clint  Lewis 
and  his  wife,  Nancy,  Dave  and  Felicity  Kemmerly,  and 
Beverly  and  I made  and  renewed  many  important 
contacts  among  our  congressional  delegations  and  their 
staffs. 

My  last  trip  was  to  honor  Senator  Breaux  who 
received  the  Nathan  Davis  Award  presented  by  the  AM  A. 
He  was  nominated  by  the  LSMS  and  was  selected  for  his 
work  and  expertise  in  a variety  of  key  health  policy  areas. 
As  Chairman  of  the  National  Bipartisan  Commission  on 
the  Future  of  Medicare,  he  worked  to  ensure  that  senior 
citizens  have  a strong  Medicare  program.  The 
Commission  did  not  reach  the  required  super  majority 
for  a consensus  report;  however,  its  findings  may  serve 
as  the  basis  for  a bill  that  will  likely  be  introduced  and 
debated  before  the  Congress. 

The  AMA  Leadership  Development  Conference  was 
held  in  Phoenix.  It  is  always  interesting,  and  well  worth 
our  leaders  attending.  Y2K  was  a major  concern.  Fraud 
and  abuse  and  compliance  were  big  topics.  AMAP  was 
again  a controversial  topic  of  discussion.  Managed  care 
and  many  of  the  following  problems  were  extensively 
discussed:  arbitrary  denials,  external  review  procedures, 
health  plan  accountability  when  negligent  medical 
decisions  cause  injury  or  death,  gag  practices,  access  to 
adequate  information  from  health  plans,  prudent 
layperson  standards  for  emergency  services,  choice  of 
care,  continuity  of  medical  care,  access  to  specialty  care, 
preemption  of  state  laws  by  federal  legislation.  The 
keynote  speaker,  former  President  George  Bush,  was 
fantastic.  It  was  a great  conference  to  prepare  our  future 
leaders.  The  LSMS  was  represented  by  myself,  Dr.  Clint 
Lewis,  and  two  members  of  the  LSMS  staff.  In  addition, 
there  was  excellent  attendance  by  several  of  our 
component  societies. 

I attended  the  AMA  Interim  Meeting  in  Hawaii.  It  was 
a tough  assignment,  but  someone  had  to  do  it!  AMAP 
was  once  again  extensively  discussed.  There  were  no  final 
conclusions,  and  the  AMA  was  to  continue  the  project. 
There  was  little  enthusiasm  voiced  for  AMAP. 
Membership  was  a common  problem  to  all  states  as  well 
as  the  AMA.  The  Advocacy  Recourse  Center  (ARC)  rolled 
out  its  initial  set  of  state  advocacy  campaigns.  I was 
extremely  impressed  with  the  materials  as  something 
valuable  for  use  by  state  societies.  One  of  the  highlights 
of  the  meeting  was  the  vote  to  pursue  collective 
negotiation  for  physicians.  However,  the  AMA  Board  of 
Trustees  didn't  finalize  action  on  this  house  mandate.  This 
created  much  discussion  in  Chicago  for  the  annual  AMA 
meeting. 

For  the  AMA  Annual  Meeting  in  Chicago,  the  main 
topic  was  collective  negotiation  for  physicians.  The  final 
conclusion  was  that  the  AMA  would  assist  employed 
physicians  and  certain  residents  who  want  to  establish 


collective  bargaining  units.  It  is  not  currently  legal  for  self- 
employed  physicians  to  collectively  negotiate.  Thus,  the 
AMA  action  would  only  apply  to  approximately  one  in 
seven  physicians.  Before  forming  collective  bargaining 
units,  the  AMA  would  encourage  negotiation  with  the 
assistance  of  its  legal  counsel.  A "no  strike"  policy  would 
be  observed  for  five  years.  Another  focus  at  the  meeting 
was  membership.  The  AMA  Membership  Task  force 
agreed  to  continue  its  work. 

Louisiana  physicians  must  continue  to  realize  that 
there  has  to  be  a solid,  strong  voice  for  medicine  and 
patients  in  every  arena  where  healthcare  is  an  issue.  There 
absolutely  cannot  be  a vacuum  of  representation  because 
it  will  be  filled  by  someone  or  something,  usually  a 
nonphysician  organization.  In  the  frustration  of  us  trying 
to  deal  with  all  of  the  changes  occurring  in  healthcare  we 
have  let  our  individual  differences  overshadow  the 
awareness  of  a need  for  physician  unification  and  a strong 
organization  to  represent  us.  We  don't  always  agree  and 
never  have,  never  will.  But,  the  one  thing  we  have  always 
had  is  the  ability  to  put  the  best  interests  of  our  patients 
and  profession  first.  That  is  what  makes  us  different.  And 
that  is  what  should  make  us  strong  as  we  organize  to  do 
what  is  right.  The  LSMS  is  the  premier  advocate  for 
patients  and  physicians  in  Louisiana.  It  is  a volunteer 
organization.  This  is  our  Medical  Society.  Let's  make  it 
the  best  that  it  can  be. 

This  report  would  not  be  complete  without  my 
heartfelt  thanks  to  the  excellent,  dedicated  staff  of  the 
LSMS.  Until  you  have  worked  with  this  professional 
group  of  men  and  women,  interested  in  good  medicine, 
and  committed  to  the  welfare  of  our  patients,  and  our 
physicians,  you  cannot  appreciate  the  support  that  they 
have  given  me.  It  has  been  a great  year!  They  made  it 
happen! 

Leo  L.  Lowentritt,  Jr.,  MD 
President,  Louisiana  State  Medical  Society 


Supplement  6 VOL  152  March  2000  J La  State  Med  Soc 


Secretary/T  reasurer 


The  slow  decline  in  membership  totals  continues 
but  the  Louisiana  State  Medical  Society 
remains  in  a strong  financial  position.  This  past 
year  there  has  been  the  added  strain  on  Society  finances 
due  to  several  extra  unbudgeted  items.  This  includes 
the  Leadership  Conference  and  the  Managed  Care 
Summit  meting  with  the  Insurance  Commissioner  and 
health  care  providers.  Uncertainty  around  the  cost  of 
House  of  Delegates  resolutions  with  fiscal  notes  also 
makes  accurate  budget  projections  difficult. 

This  year  we  planned  the  Society's  budget  based 
on  more  reasonable  membership  totals.  The  resultant 
smaller  dues  income  projection  has  led  to  much  hard 
work  to  decide  what  services  we  provide  are  the  most 
productive  for  the  membership.  This  has  been  necessary 
to  present  a balanced  budget  for  House  of  Delegate 
approval  and  to  keep  our  expenses  under  control  to 
prevent  a dues  increase. 

The  investment  committee  has  maintained  its 
conservative  approach  to  our  investments  that  has 

LSMS  Membership 

Active  Members 
Dues-Exempt  Members 
Service  Members 
Academic  Members 
Resident  Members 
Medical  Student  Members 
Active  Part-time  Members 
Corresponding  Members 


withstood  the  recent  stock  market  fluctuations.  We  are 
looking  for  a $300,000  contribution  on  gains  on  these 
invested  funds  to  help  us  balance  the  budget. 

Owing  to  the  continued  decline  in  LSMS 
membership,  it  is  imperative  that  the  LSMS 
Membership  Committee  and  the  various  component 
societies  increase  their  efforts  to  enlarge  our  active  dues 
paying  membership  base.  The  Society  provides  services 
the  benefit  all  physicians,  not  just  active  members,  so 
this  message  needs  to  be  communicated  throughout  the 
medical  community  if  we  are  to  continue  providing 
these  benefits  for  all. 

The  staff,  with  oversight  from  the  Budget  and 
Finance  Committee,  continues  to  provide  a prudent 
financial  approach  to  our  expenses.  We  owe  a great  deal 
of  gratitude  to  their  vigilance  on  behalf  of  our  financial 
resources. 

Wallace  H.  Dunlap,  MD 
Secretary /Treasurer 


1999 

1998 

1997 

4,539 

4,672 

4,713 

790 

743 

743 

9 

8 

6 

3 

3 

3 

712 

571 

133 

843 

921 

485 

11 

7 

0 

5 

5 

0 

Total  6,912  6,930  6,083 

The  1998  and  1997  figures  are  year-end  totals.  The  1999  totals  are  as  of  September  30, 1999. 


AMA  Membership 


1999 

1999 

1999 

1998 

1998 

1998 

1997 

1997 

1997 

LSMS 

Direct 

Total 

LSMS 

Direct 

Total 

LSMS 

Direct 

Total 

Regular 

1,419 

920 

2,339 

1,369 

1023 

2,392 

1,520 

985 

2,505 

Dues  Exempt 

328 

160 

488 

338 

125 

463 

339 

93 

432 

Resident 

635 

416 

1,051 

455 

409 

864 

31 

506 

537 

Military 

0 

0 

0 

0 

0 

0 

0 

0 

0 

Medical  Student 

665 

465 

1,130 

680 

242 

922 

751 

256 

1,007 

Totals 

3,047 

1,961 

5,008 

2,842 

1,799 

4,641 

2,641 

1,840 

4,481 

The  1999,  1998  and  1997  figures  are  year-end  totals. 
These  figures  taken  from  the  AMA  Membership  Report. 


Supplement  7 VOL  152  March  2000  J La  State  Med  Soc 


A 


The  following  is  a summary  of  the  actions  of  the 
Board  of  Governors  (BOG)  since  the  last  Annual 
Meeting,  extracted  from  the  official  minutes.  For  a 
complete  report,  please  refer  to  approved  minutes. 

APRIL  7, 1999 

The  following  actions  were  taken  by  the  board: 

1.  Referred  to  the  Executive  Committee  the 
establishment  of  annual  dates  for  the  LSMS 
Leadership  Conference. 

2.  Referred  the  issue  of  defining  unexcused  absence  for 
committee  meetings  to  the  Executive  Committee. 

3.  Voted  to  approve  $2000  for  participation  in  the  AM  A 
Nathan  Davis  Award  Dinner  and  Reception  honoring 
Senator  John  Breaux  should  he  be  selected. 

4.  Directed  staff  to  compose  a letter  and  send  to  the  24 
statewide  specialty  societies  for  co-signature  with  the 
LSMS  opposing  Representative  Rodney  Alexander's 
bill  HB  1070  which  would  change  the  composition  of 
the  Board  of  Medical  Examiners  adding  specialty 
designations  on  the  LSBME  as  well  as  Hospital 
Association  appointees. 

5.  Authorized  the  Executive  Vice  President  to  begin 
negotiations  with  Bickerstaff  and  Whatley  for  an 
independent  actuarial  review  of  the  Patients 
Compensation  Fund.  The  board  directed  that  a 
negotiated  contract  with  Bickerstaff  and  Whatley 
should  not  exceed  $20,000. 

6.  Directed  that  a special  bulletin  be  sent  to  all  members 
of  the  LSMS  explaining  what  the  PCF's  actuaries  have 
recommended  for  increasing  the  premium  rates  and 
the  current  legislative  bills  effecting  the  PCF  cap. 

7.  In  response  to  a request  from  the  Chair  of  the  Hall  of 
Fame  Committee  for  clarification  of  the  policy 
governing  nominations,  the  board  voted  to  send  to 
the  committee  the  current  HOD  policy  which  does 
not  place  limits  on  the  numbers  of  nominees  other 
than  to  specify  that  no  more  than  one  deceased 
physician  per  year  should  be  nominated. 

8.  Approved  the  actions  of  the  ad  hoc  committee 
established  by  the  Executive  Committee  to  draft 
legislation  addressing  prescribing  of  controlled 
substances  by  non-physicians  and  APRN  supervision 
of  prescribing  authority. 

9.  Voted  to  accept  the  recommendation  from  Lynn 
Hickman,  MD,  Medical  Director  of  Medicare  Services, 
Louisiana  Part  B Operations,  to  revise  the  contract 
for  the  Medical  Services  Review  Committee.  The 
change  will  eliminate  the  designation  of  two  OB/ 
GYNs  to  the  core  committee  of  general  practitioners, 
internists,  and  general  surgeons  and  those  specialties 


will  increase  from  two  to  three  members  per  specialty 
for  a total  of  nine  members. 

10.  Following  a recommendation  by  the  Committee  on 
CME  Accreditation  voted  to  approve  the  adoption  of 
the  revised  Essential  7 of  the  ACCME  Essentials  and 
Standards  as  a new  policy  of  the  LSMS  CME 
Accreditation  Program. 

11.  Approved  forwarding  a resolution  to  the  AMA 
Delegation  for  submission  to  the  AMA  House  of 
Delegates  Annual  Meeting  in  June  which  requires  the 
AMA  to  obtain  from  HCFA  a definition  of  the  term 
"screening"  as  it  relates  to  diagnostic  and  pre- 
operative testing  for  Medicare  patients. 

12.  Reviewed  the  results  of  the  AMAP  survey  and 
forwarded  the  information  to  the  AMA  delegation. 

13.  Following  the  recommendation  of  Dr.  Benson  Scott, 
authorized  the  Executive  Committee  to  choose  a 
company  to  do  the  technical  management  of  the  LSMS 
website  full-time. 

14.  Approved  guidelines  for  the  LSMS  to  co-sponsor 
statewide  specialty  society  functions  with  legislators 
with  the  approval  of  the  Executive  Committee. 
Specialty  societies  will  coordinate  the  event  with  the 
Department  of  Governmental  Affairs.  The  board  set 
LSMS  cost  sharing  at  one  half  of  the  actual  cost  of  the 
event  up  to  a maximum  of  $500.  The  LSMS  will 
participate  in  only  one  event  per  specialty  society  per 
year. 

15.  Approved  a motion  from  the  Evolving  Trends  in 
Medicine  Committee  relieving  the  committee  from  the 
responsibility  of  carrying  out  resolution  97-303  as  the 
committee  felt  that  the  AMA's  Education  for 
Physicians  on  End  of  Life  Care  (EPEC)  Program  was 
adequately  addressing  the  issue. 

16.  Amended  a motion  submitted  by  the  Committee  on 
Mental  Health  and  Substance  Abuse  Disorders  to  state 
that  the  LSMS  supports  parity  for  mental  illness  in 
the  LACHIP  program. 

17.  Approved  a request  submitted  by  the  Disaster  and 
Emergency  Services  Committee,  regarding  resolution 
98-304,  for  them  to  disseminate  the  resolution 
outlining  guidelines  for  emergency  room  physicians 
to  all  hospitals'  chiefs  of  staff  and  administrators. 

18.  Amended  a motion  submitted  by  the  Committee  on 
Medical  Education  that  the  LSMS  send  a letter  to  the 
LSBME  recommending  that  60  hours  of  AMA  PRA 
Category  1 continuing  medical  education  credit  over 
a three-year  period  be  required  for  licensure  and 
relicensure  in  Louisiana  and  to  recommend  to  the 
LSBME  that  they  consider  the  Arkansas  State  Medical 
Board  Regulation  No.  17  on  continuing  medical 


SuDDlement  8 VOL  152  March  2000  J La  State  Med  Soc 


education  as  an  example  of  how  a requirement  can 
be  established. 

JUNE  9,  1999 

The  following  actions  were  taken  by  the  board: 

1.  Voted  to  rescind  its  action  taken  on  April  7,  1999  to 
relieve  the  Committee  on  Evolving  Trends  In  Medicine 
of  the  responsibility  of  resolution  97-303. 
Recommended  the  committee  make  its  request 
directly  to  the  House  of  Delegates. 

2.  Directed  the  Executive  Committee  finalize  the  LSMS 
response  to  the  latest  revision  of  the  Surveillance  and 
Utilization  Review  Services  (SURS)  Rules  from  DHH. 

3.  Approved  the  mailing  of  a letter  to  the  LSMS 
membership  concerning  the  second  stock  offering  of 
MD  Healthshares  Corporation. 

4.  Regarding  HB  2280,  the  Board  directed  that  the 
Department  of  Governmental  Affairs  continue  to 
monitor  the  bill  and  to  actively  oppose  it  if  it  gets  to 
the  floor  of  the  Senate. 

5.  Directed  that  a letter  be  sent  out  to  all  physicians  in 
Louisiana  from  the  LSMS  President  and  the  individual 
component  society  President,  outlining  the 
accomplishments  of  the  LSMS  legislative  efforts  this 
year  on  behalf  of  all  physicians. 

6.  Voted  to  request  the  results  of  the  LSMS  AMAP 
Survey  be  published  in  the  Journal. 

7.  In  response  to  a request  from  the  AMA,  the  Board 
voted  to  provide  the  results  of  the  AMAP  Survey  to 
the  AMA  deleting  specific  references  to  any  states  or 
specialty  society. 

8 . Voted  to  request  the  ad  hoc  committee  on  the  Structure 
and  Functioning  of  the  House  of  Delegates  review  the 
criteria  for  inclusion  of  resolutions  printed  in  the 
Directives  of  the  HOD. 

9.  In  response  to  the  letter  of  resignation  from  Melanie 
Firmin,  MD,  the  Board  voted  to  appoint  Elwyn  Lyles, 
MD,  to  complete  the  unexpired  term  as  Alternate 
Councilor  for  the  Eighth  District. 

10.  Requested  that  the  ad  hoc  committee  on  the  Structure 
and  Functioning  of  the  HOD  consider  the 
recommendations  of  the  Board  of  Councilors  for 
modifying  the  LSMS  Resident  Section.  Voted  to  inform 
the  AMA  for  possible  publication  in  AMNezvs  that  the 
Louisiana  Attorney  General's  office  has  issued  an 
opinion  supporting  the  LSBME's  statement  which 
affirmed  that  medical  necessity  decisions  in  Louisiana 
should  be  made  only  by  physicians  licensed  in  the 
state  of  Louisiana. 

11.  Authorized  the  Executive  Committee  to  determine  at 
what  level  the  Society  will  participate  in  the  Corporate 
Round  Table  following  the  legislative  session  based 
upon  a recommendation  by  the  staff  of  the  Office  of 
Governmental  Affairs. 

12.  Directed  that  Legal  Counsel  for  the  LSMS  investigate 
possible  legal  options  against  the  State  Employee 


Benefits  Group  Insurance  Program  due  to  continued 
miscommunication  with  physicians  regarding  their 
contracts  with  the  program. 

13.  Voted  to  purchase  a table  at  the  Patron  level  for  the 
Nathan  Davis  Award  Banquet  in  Washington  DC  in 
July  which  honors  Senator  John  Breaux.  Senator 
Breaux  was  nominated  for  the  award  by  the  LSMS. 

14.  Directed  the  President  to  appoint  an  ad  hoc  committee 
to  examine  the  current  standing  committee  structure 
of  the  LSMS  and  to  make  recommendations  as  to 
whether  some  committees  could  be  combined  in  order 
to  create  fewer  committees  with  a stronger  interest 
base. 

15.  Approved  a recommendation  from  the  Executive 
Committee  and  set  the  date  for  the  annual  Leadership 
Conference  for  the  first  weekend  in  February  except 
in  those  years  where  Mardi  Gras  might  conflict 
directly  with  that  meeting.  The  meeting  will  be  a one- 
day  event,  preferably  on  a Saturday. 

16.  Directed  Legal  Counsel  for  the  LSMS  to  proceed  with 
the  purchase  of  the  Texas  Medical  Association's  Fraud 
and  Abuse  Handbook  which  would  then  be  modified 
into  a model  fraud  and  abuse  compliance  plan  for 
physician  offices. 

17.  Approved  a motion  from  the  Committee  on  Geriatrics 
to  contact  Lynn  Hickman,  Medical  Director  of 
Medicare  Services,  and  recommend  that  a geriatrician 
be  added  to  the  Medicare  Carrier  Advisory 
Committee. 

18.  Approved  a motion  from  the  Committee  on  Geriatrics 
to  provide  the  Department  of  Health  and  Hospitals 
with  a list  of  LSMS  physicians  who  volunteer  to 
review  cases  of  potential  fraud  and  abuse  and  neglect 
in  terminally  ill  patients  in  Medicaid  hospice 
programs. 

19.  Based  on  the  recommendation  of  the  Committee  on 
Geriatrics,  the  Board  agreed  to  direct  the  AMA 
Delegation  to  oppose  any  guidelines  by  HCFA  for  use 
of  non-medically  trained  state  surveyors  of  long  term 
care  facilities  that  evaluate  physician  prescribing 
practices. 

20.  Referred  to  the  Executive  Committee  the  request  from 
Medicare  Part  B for  the  name  of  a nominee  to  replace 
an  internist  on  the  Medical  Services  Review 
Committee. 

21.  Approved  a recommendation  from  the  CME 
Accreditation  Committee  to  adopt  the  New  Essentials 
and  Criteria  as  proposed  by  the  Accreditation  Council 
for  Continuing  Medical  Education  (ACCME)  as  the 
standard  for  the  LSMS  Continuing  Medical 
Accreditation  Program  in  Louisiana. 

SEPTEMBER  7 AND  8,  1999 

The  following  actions  were  taken  by  the  board: 

1.  Approved  a motion  to  submit  a resolution  to  the 
House  of  Delegates  to  amend  LSMS  policy 


Supplement  9 VOL  152  March  2000  J La  State  Med  Soc 


concerning  emergency  room  physician  qual- 
ifications. 

2.  Approved  a resolution  to  the  House  of  Delegates 
which  would  develop  a mechanism  for  prioritizing 
the  LSMS  legislative  agenda. 

3.  In  response  to  the  AMA  regarding  the  Norwood- 
Dingle  Bill,  the  Board  voted  to  support  in  principle 
the  concept  of  any  patients'  bill  of  rights  bill  as  it 
does  not  conflict  with  any  current  LSMS  policies. 

4.  Approved  a resolution  to  the  House  of  Delegates 
which  calls  for  legislation  which  would  allow 
physicians  the  ability  to  collectively  negotiate  with 
insurance  and  managed  care  companies. 

5.  Voted  to  submit  the  names  of  the  following 
physicians  to  the  Governor  for  his  consideration  for 
appointment  to  the  Louisiana  State  Board  of  Medical 
Examiners.  The  Governor  will  select  three 
physicians  from  the  list: 

Jack  Andonie,  MD  Ray  Lousteau,  MD 
K.  Barton  Farris,  MD  Janis  Letourneau,  MD 
Edward  Frohlich,  MD  John  Moffett,  MD 
Lynn  Hickman,  MD  Richard  Nunnally,  MD 
Trent  James,  MD 

6.  Voted  to  submit  the  names  of  the  following 
physicians  representing  a parish  or  municipality 
with  a population  of  less  than  20,000  people  to  the 
Governor  for  his  consideration  for  appointment  to 
the  Louisiana  State  Board  of  Medical  Examiners.  The 
Governor  will  select  one  physician  from  the  list: 

Alonzo  Diodene,  MD 
Kim  Edward  LeBlanc,  MD 
David  Post,  MD 

7.  Approved  the  names  of  delegates  to  the  LSMS  House 
of  Delegates  for  the  LSU  School  of  Medicine,  Tulane 
University  School  of  Medicine,  the  Resident  Section 
and  the  Medical  Student  Section. 

8.  Voted  to  submit  a proposed  2000  budget  of 
$2,290,980.00  prepared  by  the  Budget  and  Finance 
Committee  to  the  House  of  Delegates. 

9.  Recommended  an  ad  hoc  committee  be  formed  to 
study  the  standing  committee  structure  of  the  LSMS 
and  how  the  LSMS  conducts  its  business  and  report 
its  recommendations  to  the  Board  during  the 
Strategic  Planning  Retreat  in  May  of  2000. 

10.  Approved  an  amended  revision  of  the  LSMS 
Expense  Reimbursement  Policy  for  attendance  at 
committee  and  BOG  meetings  as  proposed  by  the 
Budget  and  Finance  Committee. 

11.  Referred  the  issue  of  reviewing  society-sponsored 
health  insurance  program  as  a member  benefit,  to 
both  the  Insurance  Committee  and  the  Membership 
Committee  for  further  study. 

12.  Approved  a request  from  the  Maternal  and  Perinatal 
Health  Committee  to  maintain  the  LSMS  mem- 
bership in  the  Louisiana  Maternal  and  Child  Health 
Coalition  on  an  organizational  level  of  $1000.00 


annually. 

13.  Approved  a request  from  the  AMA  Delegation  for 
an  additional  $5000.00  to  help  defray  the  higher  costs 
associated  with  the  airfares  and  hotels  at  the  San 
Diego  Interim  Meeting  in  December  1999. 

14.  Voted  to  establish  a Board  of  Governors  policy  not 
to  reimburse  expenses  for  any  LSMS  officer  to  attend 
or  participate  in  political  fundraising  functions. 

15.  Regarding  the  4th  resolve  of  substitute  resolution  98- 
104,  voted  to  send  a letter  inviting  the  AMA  to 
conduct  an  educational  program  for  LSMS  members 
to  learn  about  the  AMAP  program. 

16.  Voted  to  submit  a resolution  to  the  House  of 
Delegates  requesting  the  AMA  study  and  report  on 
the  extent  of  possible  physician  fraud  and  abuse  in 
the  Medicare  program  in  order  to  determine  those 
cases  which  can  actually  be  proven  to  be  fraud  and 
not  inadvertent  coding  or  documentation  errors  on 
the  part  of  physicians. 

17.  Voted  to  submit  a resolution  to  the  House  of 
Delegates  calling  for  the  AMA  to  consider  joining 
with  other  health  care  professional  organizations  in 
legislative  and  legal  actions  which  would  cause  the 
government  to  cease  and  desist  from  issuing  inflated 
accusations  of  fraud  and  abuse  by  health  care 
providers  and  asking  the  AMA  Delegation  to 
introduce  a resolution  to  this  effect  at  the  AMA 
Interim  Meeting  in  December. 

18.  Approved  a motion  from  the  Public  Relations 
Committee  calling  for  the  LSMS  to  establish  a high 
school  medical  journalism  contest  awarding  two 
prizes  of  $250  each  for  the  top  winners  in  both  print 
and  media  broadcast  categories  and  voted  to  sponsor 
a two-parish  pilot  project  during  the  1999-2000 
school  year  to  determine  its  success  with  possible 
implementation  in  other  parishes  in  future  years. 

19.  Approved  the  amended  purpose  and  charges  of  the 
Committee  on  CME  Accreditation  as  proposed  by 
the  committee. 

20.  Approved  the  amended  purpose  and  charges  of  the 
Committee  on  Mental  Illness  and  Substance  Abuse 
Disorders  as  proposed  by  the  committee. 

21.  Referred  back  to  the  Ad  Hoc  Committee  on  the 
Operation  and  Functioning  of  the  House  of 
Delegates  the  question  of  what  should  be  done  to 
get  more  medical  organizations  involved  in  the 
LSMS  House  of  Delegates  as  official  observers. 

22.  Voted  to  take  no  action  on  a recommendation  from 
the  Budget  and  Finance  Committee  to  establish  a 
policy  that  any  component  society  that  collects  and 
holds  LSMS  dues  beyond  February  1st  shall  be 
subject  to  a monetary  penalty. 

23.  Voted  to  publish  a letter  or  article  in  Capsules 
supporting  the  effort  of  the  Louisiana  Health  Care 
Review's  campaign  to  publicize  the  need  for  the 
elderly  to  be  vaccinated  against  influenza. 


SuDDlement  10  VOL  152  March  2000  J La  State  Med  Soc 


24.  Amended  a motion  submitted  by  the  Managed  Care 
Liaison  Committee  and  referred  to  the  Public 
Relations  Committee  the  issue  of  supporting  the 
concept  of  individually  owned  health  insurance,  by 
publishing  articles  in  Capsules  and  the  Journal  and 
by  letters  to  the  editor  and  press  releases  for 
statewide  disbursement. 

25.  Referred  back  to  the  Disaster  and  Emergency 
Medical  Services  Committee  a motion  asking  for 
support  from  the  BOG  to  send  a letter  to  the 
Department  of  Health  and  Hospitals  recommending 
specific  guidelines  for  the  use  of  automated  external 
defibrillators  until  such  time  as  the  committee 
develops  those  guidelines  and  composes  a draft 
letter  for  the  BOG  to  review. 

26.  Approved  a letter  prepared  by  the  Disaster  and 
Emergency  Medical  Services  Committee  to  be  sent 
to  EMS  Directors  explaining  the  personal  liability 
issue  for  EMS  Directors  who  sign  ambulance 
certification  forms  for  controlled  dangerous 
substances. 

27.  Referred  back  to  the  Disaster  and  Emergency 
Medical  Services  Committee  a motion  asking  for 
support  from  the  BOG  to  disseminate  materials  to 
ambulance  providers  regarding  reimbursement  of 
the  ambulance  services  by  the  prudent  lay  person, 
until  the  committee  can  clarify  such 
recommendations. 

28.  Agreed  to  co-sponsor  a resolution  with  the  AMA 
Delegation  to  the  HOD  establishing  the  delegation 
reimbursement  guidelines  as  approved  by  the 
delegation  at  its  summer  caucus  with  the  addition 
that  the  maximum  allowable  amount  per  delegate 
is  to  be  set  annually. 

29.  Approved  a motion  from  the  Membership 
Committee  recommending  the  LSMS  implement  a 
recognition-based  peer-to-peer  recruitment  program 
without  incentive  awards  to  stimulate  active 
physician  participation  in  recruitment  and  retention 
of  members. 

30.  Approved  a motion  from  the  Membership 
Committee  recommending  the  LSMS  develop  a lapel 
pin  signifying  membership  in  the  LSMS. 

31.  Approved  a motion  from  the  Membership 
Committee  to  establish  a recruitment  and  retention 
assistance  program  for 

DECEMBER  15,  1999 

The  following  actions  were  taken  by  the  board: 

1.  Approved  recommendations  from  the  Vice-President 
concerning  operation  of  the  LSMS  website  and 
requested  that  he  develop  policies  and  procedures  for 
posting  information  on  the  website  to  be  approved 
by  the  Board  at  a later  date. 

2.  Determined  that  the  charges  of  the  ad  hoc  website 


committee  had  been  accomplished.  Voted  to  place 
appropriate  recognition  of  the  committee  and  its  chair, 
Benson  Scott,  MD,  on  the  home  page  of  the  website 
in  appreciation  of  their  work  in  getting  the  website 
up  and  running. 

3.  Following  up  discussion  at  the  September  Board 
meeting,  established  an  hoc  committee  to  examine  the 
LSMS  standing  committee  structure  and  charged  the 
committee  with  developing  recommendations  to  be 
presented  during  the  Strategic  Planning  Retreat  in 
June  of  2000. 

4.  Reviewed  resolutions  from  the  House  of  Delegates 
and  took  the  following  actions: 

a.  99-101,  4th  resolve.  Sunset  Mechanism  for  House 
of  Delegates  Generated  Policy — referred  315.96, 
Medical  Record  Privacy  and  320.99,  Third  Party 
Requests  for  Information  to  the  Legal  Affairs 
Department  and  315.98,  Handling  of  Deceased 
Physicians'  Medical  Records  and  435.91, 
Guidelines  for  Malpractice  Case  Review  by 
Physicians  to  the  Medical  /Legal  Interprofessional 
Committee. 

b.  99-109,  Physician  Office  Medical  Records  Release 
Guidelines — referred  to  the  Legal  Affairs 
Department. 

c.  99-110,  Formation  of  LSMS  Rural  Caucus — 
Speaker  and  Vice-Speaker  of  the  HOD  have 
already  established  a meeting  of  the  caucus  to  be 
held  on  the  Friday  morning  of  the  Annual 
Meeting.  David  Post,  MD  has  been  appointed 
chair  of  the  caucus. 

d.  99-111,  Annual  Physician  Award  for  Community 
Service — referred  to  the  Board  of  Councilors  for 
development. 

e.  99-115,  Component  Society  Meetings  with  Area 
Legislators — referred  to  the  Council  on 
Legislation  and  the  Department  of  Governmental 
Affairs. 

f.  99-119,  Operations  and  Functions  of  the  House 
of  Delegates,  10th  resolve  only — the  President  will 
send  invitation  letters  to  the  appropriate  physician 
medical  organizations  inviting  them  to  apply  for 
Official  Observer  status. 

g.  99-202,  Medicaid  Reimbursement — Dr.  Lewis  will 
present  the  summary  of  the  ABC  Plan  for 
Medicaid  reform  to  the  Department  of  Health  and 
Hospitals  on  December  17,  1999  during  a special 
conference  called  by  DHH. 

h.  99-206,  Online  Prescriptive  Drug  Services  and 
Promotion  of  Unconventional  Treatment 
Therapies,  2nd  and  3rd  resolves  only — referred  to 
the  President  to  write  appropriate  letters  to  the 
Board  of  Medical  Examiners  requesting  guidelines 
and  rules  for  internet  prescribing. 

i.  99-211,  Hospital  Disclosure  and  Quality 


Supplement  11  VOL  152  March  2000  J La  State  Med  Soc 


Improvement,  1st  and  3rd  resolves  only — voted  to 
postpone  action  until  the  March  BOG  in  order  to 
allow  staff  to  evaluate  the  most  prudent  means 
of  communicating  with  other  health  care 
professionals.  Determined  that  the  2nd  and  4th 
resolves  constitute  existing  LSMS  policy  and 
required  no  further  action. 

j.  99-226,  Collection  of  Local  /Parish  Sales  Tax  for 
Use  and/or  Administration  of  Drugs  in 
Physicians'  Practices — referred  to  the  Council  on 
Legislation  and  the  Department  of  Governmental 
Affairs. 

k.  99-227,  Legislative  Priorities  and 
Implementation — referred  to  the  Executive 
Committee  and  the  Council  on  Legislation. 

l.  99-228,  Joint  Negotiations  by  Physicians  with 
Health  Insurance  Issuers — referred  to  the 
Department  of  Governmental  Affairs  for 
investigation  and  development  of  legislation. 

m.  99-301,  Osteoporosis  Prevention — referred  to  the 
editor  of  the  Journal  to  write  an  article  for 
publication  on  the  subject. 

n.  99-304,  Emergency  Preparedness — directed  the 
President  to  write  a letter  to  the  component  society 
presidents. 

o.  99-306,  Discarding  of  Drugs  in  Nursing  Homes — 
directed  the  President  to  write  to  the  Board  of 
Pharmacy. 

p.  99-401,  Federal  Funding  Reimbursement 
Coverage  Differential — referred  to  the 
Department  of  Governmental  Affairs. 

q.  99-402,  Necessity  to  Have  a License  to  Practice 
Medicine — directed  staff  to  communicate  with 
officials  at  DHH  and  the  Department  of  Insurance. 

r.  99-403,  PRO  Project — directed  the  President  to 
write  a letter  to  the  Director  of  the  PRO,  Dr.  Tony 
Sun. 

s.  99-404,  Policy  on  Physician  Negotiating  Units — 
1st  resolve  determined  to  be  policy  therefore  no 
additional  action  was  required.  2nd  resolve 
referred  to  the  Public  Affairs  Department,  the 
Public  Relations  Committee  and  the  Journal. 

t.  99-405,  Public  Communication  on  Differences  in 
Educational  and  Professional  Standards  Between 
Physicians  and  Non-Physician  Healthcare 
Providers — referred  to  LSMS  staff  for  study  and 
development. 

u.  99-408,  Implementation  of  Payment  Timeliness 
Survey — directed  that  staff  study  the  survey 
instrument  developed  by  the  AMA's  Advocacy 
Research  Center  and,  if  appropriate,  post  it  on  the 
LSMS  website  with  results  totaled  for  presentation 
at  the  September  BOG. 

v.  99-409,  Health  Plan  "In-Network"  Hospitals — 
referred  to  the  Department  of  Legal  Affairs  to 


work  with  the  Department  of  Insurance. 

w.  99-410,  Proper  Notification  and  Education 
Regarding  Healthcare  Provider  Shortage  Areas  by 
Carrier — no  need  for  additional  action  as  the  BOG 
felt  the  issue  was  being  well-published  in  Capsules. 

x.  99-411,  Code  of  Conduct  for  Health  Insurance 
Entities /Managed  Care  Organizations — referred 
to  Insurance  Committee. 

y.  99-412,  Establishment  of  Service  to  Review  Health 
Insurance  / Managed  Care  Organization  Contracts 
and  Provide  Comparison  Data  to  Members — 
referred  to  the  Department  of  Legal  Affairs. 

5.  Appointed  Drs.  Juan  Watkins  and  Tom  Meek  as  the 
active  members  of  the  ERF  from  the  HOD. 

6.  Approved  changes  to  the  LSMS  Employee  Manual  to 
conform  with  new  state  laws  and  the  new  40 IK  plan. 

7.  In  response  to  a letter  from  the  Governor's  office, 
voted  to  submit  the  name  of  Robert  Hernandez,  MD, 
as  a nominee  to  the  Louisiana  State  Board  of  Medical 
Examiners  as  replacement  for  Dr.  Lynn  Hickman  who 
had  withdrawn  his  name  from  consideration. 

8.  Reviewed  a proposal  from  CSRS  concerning 
development  of  the  courtyard  area  at  the  LSMS 
headquarters  building  and  asked  that  further  research 
on  costs  be  done  and  brought  back  to  the  Board. 

9.  Reviewed  the  actuarial  study  of  the  Patients 
Compensation  Fund  by  the  firm  of  Bickerstaff  and 
Whately  and  voted  to  continue  development  of  some 
aspects  of  the  study. 

10.  Approved  indemnification  recommendations  for 
Dave  Tarver,  Jeanette  Harmon,  and  Bryan  LaHaye  as 
Plan  Administrators  for  the  LSMS  Employee  401K 
Plan. 

11 . Following  a recommendation  from  the  Managed  Care 
Liaison  Committee,  directed  that  an  article  be 
published  in  Capsules  outlining  the  accomplishments 
of  the  standardized  credentialing  subcommittee 
commending  them  on  the  successful  development  of 
the  new  standardized  credentialing  form. 

12.  Following  a request  from  the  CME  Accreditation 
Committee,  approved  the  use  of  the  LSMS  seal  placed 
beside  the  accreditation  statement  used  by  all  LSDMS 
accredited  organizations  in  Louisiana  as  a means  of 
promoting  the  LSMS  and  the  LSMS  CME 
Accreditation  Program. 

13.  Approved  an  allocation  of  $1500  to  help  defray  the 
expenses  of  the  CME  Accreditation  Committee 
members  to  attend  the  Annual  Alliance  for  CME  in 
January  in  New  Orleans. 

14.  Approved  two  motions  from  the  Chronic  Diseases 
Committee  calling  for  the  dissemination  of  posters 
supplied  by  Merck  Pharmaceuticals  and  a letter  from 
the  LSMS  President  outlining  the  need  for  primary 
care  physicians  and  gynecologists  to  test  for 
osteoporosis. 


Supplement  12  VOL  152  March  2000  J La  State  Med  Soc 


Board  of  Councilors 


The  Board  of  Councilors  is  composed  of 
representatives  of  all  ten  Louisiana  State 
Medical  council  districts.  The  chairman  of  the 
board  also  serves  on  the  Executive  Committee  of  the 
Board  of  Governors.  The  Board  of  Councilors  functions 
as  the  ethics  committee  of  the  LSMS  and  is  responsible 
for  special  tasks  and  charges  given  to  it  by  the  LSMS 
president.  All  complaints  received  by  the  committee 
were  handled  in  an  appropriate  and  prompt  fashion. 
The  board  was  also  charged  with  evaluation  of 
Resolution  98-115  which  addressed  redefining  the 
Resident  Section.  Five  recommendations  were 
forwarded  from  the  committee  to  the  Ad  Hoc 
Committee  on  Operation  and  Functioning  of  the  House 
of  Delegates  and  one  recommendation  was  forwarded 


to  the  LSMS  Executive  Vice  President  for  development 
and  possible  implementation.  The  collaborative  practice 
agreement  project  between  Louisiana  physicians  and 
the  Board  of  Pharmacy  was  completed  this  year  and 
implemented. 

As  chairman,  I have  participated  in  the  monthly 
telephone  conferences  with  the  Executive  Committee 
of  the  LSMS,  called  Budget  and  Finance  Committee 
conferences,  and  special  called  meetings  as  deemed 
necessary  by  your  president.  The  board  and  I continue 
to  serve  at  the  pleasure  of  the  component  medical 
societies  of  the  LSMS  and  its  president.  Input  is  always 
appreciated  from  our  membership. 

William  T.  Hall , MD 
Chair 


Board  of  Councilors 

William  T.  Hall,  MD 

Vincent  Culotta,  MD 

Richard  J.  Paddock,  MD  .... 

Barry  G.  Landry,  MD 

Joseph  Busby,  Jr.,  MD 

Lynn  Z.  Tucker,  MD 

R.  Mark  Williams,  MD 

Martin  B.  Tanner,  MD 

Martin  J.  Ducote,  Jr.,  MD  .. 
Marcus  L.  Pittman,  m,  MD 


Second  Distiict  and  Chair 

First  District 

Second  District 

Third  District 

Fifth  District 

Sixth  District 

Seventh  District 

Eighth  District 

Ninth  District 

Tenth  District 


Alternate  District  Councilors 


Floyd  A.  Buras,  Jr.,  MD First  District 

Tod  Engelhardt,  MD Second  District 

Walter  H.  Daniels,  MD Third  District 

Robert  Hernandez,  MD Fourth  District 

John  M.  Coats,  MD Fifth  District 

D.  Gerard  Fourrier,  MD Sixth  District 

Aretta  Rathmell,  MD Seventh  District 

William  Elwyn  Lyles,  MD Eighth  District 

Maximo  Lamarche,  MD Ninth  District 

Ralph  Maxwell,  HI,  MD Tenth  District 


Supplement  13  VOL  152  March  2000  J La  State  Med  Soc 


Budget  and  Finance 


The  Budget  and  Finance  Committee  held  three 
committee  meetings  in  1999,  and  has  been 
monitoring  closely  the  financial  situation  of  the 
LSMS.  An  important  issue  early  during  the  year  was 
the  temporary  hiring  of  two  additional  contract 
lobbyists  to  assist  the  LSMS  during  the  legislative 
session.  The  committee  voted  to  recommend  the  use  of 
undesignated  reserves  for  this  purpose.  The  session 
was  an  extremely  busy  one,  with  some  500  or  more  bills 
introduced  having  a potential  impact  on  the  practice  of 
medicine.  The  legislative  session  was  a success  for  the 
LSMS,  which  can  be  attributed  in  part  to  this  assistance. 
The  committee  has  asked  the  Board  of  Governors  to 
discuss  the  necessity  of  funding  for  additional  lobbyists 
in  future  sessions. 

The  committee  also  took  up  the  issue  of  expenses 
for  attendance  at  the  AMA  Annual  Meeting  and  Interim 
Meeting  for  any  AMA  Past-President  from  Louisiana. 
The  committee  approved  a motion  to  reimburse  the 
Past-President  of  the  AMA  for  attendance  at  both  of 
these  meetings,  at  the  same  rate  as  other  members  of 
the  Louisiana  Delegation.  Other  issues  being 
investigated  are  requests  for  proposals  from  several 
firms  to  act  as  custodian  and  investment  manager  for 
the  investment  portfolios  of  the  LSMS,  LSMS-ERF,  and 
the  Journal.  The  committee  referred  back  to  the  Board 
of  Governors  the  subject  of  reimbursement  of  expenses 
of  the  LSMS  President  for  contributions  for  political 
functions. 

At  its  July  31  meeting,  the  committee  finished 
development  of  the  FY  2000  Budget.  Noting  that 
revenue  from  membership  dues  has  been  lower  than 
forecast,  the  committee  decided  to  use  actual  1999  dues 
receipts  to  establish  a base  for  the  FY  2000  Budget.  The 


committee  feels  that  this  is  a much  more  realistic  and 
prudent  method  to  develop  the  budget.  The  initial 
budget,  in  the  amount  of  $2,290,980,  was  sent  to  the 
Board  of  Governors  for  discussion,  and  was  out  of 
balance  by  approximately  $95,000.  The  committee  sent 
a list  of  suggestions  to  the  Board  for  possible  reduction 
or  elimination  to  balance  the  budget.  At  the  September 
meeting  of  the  BOG,  the  deficit  was  reduced  to 
$55,235.00,  and  a motion  was  approved  to  make  up  the 
shortfall  by  the  use  of  undesignated  reserves.  The 
budget  for  the  Year  2000  was  approved  by  the  House  of 
Delegates  at  the  1999  Annual  Meeting.  An  issue  related 
to  the  development  of  the  budget  is  the  submission  of 
LSMS  dues  by  component  societies.  It  is  the  policy  of 
the  LSMS  that  dues  be  submitted  in  a timely  manner. 
Towards  this  end,  the  committee  approved  a 
recommendation  that  the  Board  of  Governors  establish 
a policy  that  any  component  society  that  collects  and 
holds  LSMS  dues  beyond  the  delinquency  date  of 
February  1 shall  be  subject  to  a monetary  penalty. 

The  committee  approved  a motion  that  the  Board 
of  Governors  establish  a policy  to  collect  a monetary 
penalty  from  any  component  society  that  collects  and 
holds  member  dues  beyond  February  1.  At  its 
September  meeting,  the  Board  voted  not  to  take  any 
action  on  this  request.  Finally,  the  Budget  and  Finance 
Committee  revised  the  reimbursement  policies  of  the 
LSMS  for  attendance  by  members  at  committee  and 
BOG  meetings.  These  were  sent  to  the  Board  of 
Governors  for  comment,  and  were  approved  for 
implementation. 

Martin  J.  Ducote,  Jr.,  MD 
Chair 


Budget  and  Finance  Committee 

Martin  J.  Ducote,  Jr.,  MD 

Keith  F.  DeSonier,  MD 

W.  Juan  Watkins,  MD 

Tom  J.  Meek,  Jr.,  MD 

Ralph  Maxwell,  III,  MD 

Wallace  H.  Dunlap,  MD 

Charles  D.  Belleau,  MD 


Chair 

Member 

Member 

Member 

Member 

Secretary/Treasurer 

Chair,  Council  on  Legislation 


Supplement  14  VOL  152  March  2000  J La  State  Med  Soc 


Louisiana  State  Medical  Society 
Independent  Auditor’s  Report 
to  the  Board  of  Directors 


President  and  Board  of  Directors 
Louisiana  State  Medical  Society 

Baton  Rouge,  Louisiana 

Independent  Auditor's  Report 

We  have  audited  the  accompanying  statements  of  financial  position  of  the  LOUISI  ANA  STATE 
MEDICAL  SOCIETY  as  of  December  31,  1999  and  1998,  and  the  related  statements  of  activities,  and 
cash  flows  for  the  years  then  ended.  These  financial  statements  are  the  responsibility  of  the  Society's 
management.  Our  responsibility  is  to  express  an  opinion  on  these  financial  statements  based  on  our  audits. 

We  conducted  our  audits  m accordance  with  generally  accepted  auditing  standards.  Those 
standards  require  that  we  plan  and  perform  the  audit  to  obtain  reasonable  assurance  about  whether  the 
financial  statements  are  free  of  material  misstatement.  An  audit  includes  examining,  on  a test  basis, 
evidence  supporting  the  amounts  and  disclosures  in  the  financial  statements.  An  audit  also  includes 
assessing  the  accounting  principles  used  and  significant  estimates  made  by  management,  as  well  as 
evaluating  the  overall  financial  statement  presentation.  We  believe  that  our  audits  provide  a reasonable 
basis  for  our  opinion. 

In  our  opinion,  the  financial  statements  referred  to  above  present  fairly,  in  all  material  respects,  the 
financial  position  of  the  LOUISIANA  STATE  MEDICAL  SOCIETY’  as  of  December  31, 1999  and  1998, 
and  the  changes  in  its  net  assets  and  its  cash  flows  for  the  years  then  ended  in  conformity  with  generally 
accepted  accounting  principles, 

£ 

A Professional  Accounting  Corporation 

February  3, 2000 


A Professional  Acrmmring  Corporation 

800  Two  Lake  way  Center  3810  N.  Causeway  BJvd  Metairie,  LA  70002  (304)  835*5322  PAX  (504)  835-5535 
724  £.  Boston  Street,  Covington,  LA  70433  (504)  892-5850  FAX  (504)  892-5956 
fi-Mail  Address:  laporre^la porre.  com  Internet  Address;  htrp;//wwvv.la  porte  .com/ 

Member  of  aICPA  Division  for  CPA  Firaw-Prlvatc  Companies  Practice  .Seaton  and  SEC  Practice  Section 
International  Affiliation  with  Accounting  Minis  Associated,  Jnc. 


Supplement  15  VOL  152  March  2000  J La  State  Med  Soc 


Louisiana  State  Medical  Society 
Statements  of  Financial  Position  - Audited 


ASSETS 

Cash 

Accrued  Interest  Receivable 
Investments  in  Debt  and  Equity  Securities 
Due  from  The  Journal  of  the  Louisiana 


December  31, 


1999 

1998 

56,389 

$ 49,226 

65,604 

69,222 

4,646,622 

4,682,548 

State  Medical  Society 
Investment  in  Perkins  Properties,  L.L.C. 

Deposits 

Prepaid  Expenses 

Deferred  Compensation  Agreement 

Property  and  Equipment,  Net 


41,847 

51,046 

389,646 

367,157 

690 

690 

25,238 

- 

173,391 

235,520 

156.663 

163,592 

Total  Assets 


i 5,556,090.  $ 5,619,001 


LIABILITIES 

Accounts  Payable 
Deferred  Dues  Revenue 
AMA  Dues  Payable 
Accrued  Pension  Cost 
Deferred  CME  Maintenance  Fees 
Capital  Lease  Obligation 
Accrued  Leave 

Deferred  Compensation  Liability 

Total  Liabilities 

NET  ASSETS 

Unrestricted 

Undesignated 
Board  Designated 
Temporarily  Restricted 

Total  Net  Assets 

Total  Liabilities  and  Net  Assets 


$ 19,888 

$ 37,150 

781,985 

572,753 

420 

14,490 

79,383 

55,566 

29,792 

21,500 

21,004 

4,907 

43,410 

39,116 

izajm 

235.520 

1.149.273 

98JJ1Q2 

4,292,511 

4,522,068 

60,000 

60,000 

54.306 

55,931 

4.4Q6&17 

4.637.999 

$ 5.556.090 

S 5.619.001 

Due  to  space  limitations,  notes  to  financial  statements  are  not  printed  here. 
Copies  are  available  through  the  LSMS  Membership  and  Finance  Department. 


Supplement  16  VOL  152  March  2000  J La  State  Med  Soc 


Louisiana  State  Medical  Society 

Statements  of  Activities  - 

Audited 

For  The  Years  Ended 

December  31, 

UNRESTRICTED  NET  ASSETS 

1999 

1998 

REVENUES,  GAINS,  AND  OTHER  SUPPORT 

Dues  $ 

1,703,270 

$ 

1,702,728 

Investment  Return 

268,820 

551,976 

Return  from  Joint  Venture 

22,489 

2,643 

Other  Revenues 

146.908 

152,978 

2,141,487 

2,410,325 

Net  Assets  Released  from  Restrictions 

1.625 

28,001 

Total  Revenues,  Gains  and  Other  Support 

2.143.112 

2.438.326 

EXPENSES 

Salaries,  Payroll  Taxes  and  Employee  Benefits 

1,105,884 

985,876 

Rent 

214,500 

214,500 

Subscriptions  to  The  Journal  of  the  Louisiana  State  Medical  Society 

74,580 

78,400 

Annual  Meeting  Expense 

69,668 

75,621 

American  Medical  Association  Delegates  and  Alternates 

89,859 

68,677 

Department  of  Governmental  Affairs 

136,155 

56,833 

Legal  Expenses 

31,497 

20,597 

Committees 

37,078 

30,146 

Other  Expenses 

613.448 

632.222 

Total  Expenses 

2.372J369 

2.162.872 

(Decrease)  Increase  in  Unrestricted  Net  Assets 

(229,557) 

275,454 

TEMPORARILY  RESTRICTED  NET  ASSETS 

Net  Assets  Released  from  Restrictions 

CL6_25_) 

(28.001) 

(DECREASE)  INCREASE  IN  NET  ASSETS 

(231,182) 

247,453 

NET  ASSETS  - BEGINNING  OF  YEAR 

4,637,999 

4.390.546 

NET  ASSETS  - END  OF  YEAR  $ 

4.406.817 

4.637.999 

Due  to  space  limitations,  notes  to  financial  statements  are  not  printed  here. 

Copies  are  available  through  the  LSMS  Membership  and  Finance  Department. 

Supplement  17  VOL  152  March  2000  J La  State  Med  Soc 


Louisiana  State  Medical  Society 
Comparison  of  Budget  to  Actual  - Audited 


Actual 

Unaudited 

Budget 

Variance 

Favorable 

(Unfavorable) 

REVENUE 

Dues 

$ 1,703,270 

$ 1,763,670 

$ 

(60,400) 

Investment  Return 

268,820 

278,300 

(9,480) 

Return  from  Joint  Venture 

22,489 

- 

22,489 

Other 

146.908 

157.130 

M 0.2221 

Total  Revenue 

2.141.487 

2.199.100 

(57.6131 

EXPENSES 

Salaries,  Payroll  Taxes  and  Employee 
Benefits 

1,105,884 

1,109,300 

3,416 

Rent 

214,500 

214,500 

- 

Subscriptions  to  The  Journal  of  the 
Louisiana  State  Medical  Society 

74,580 

74,575 

(5) 

Annual  Meeting  Expense 

69,668 

66,500 

(3,168) 

American  Medical  Association  Delegates 
and  Alternates 

89,859 

84,500 

(5,359) 

Department  of  Governmental  Affairs 

136,155 

70,225 

(65,930) 

Legal  Expenses 

31,497 

23,560 

(7,937) 

Committees 

37,078 

24,938 

(12,140) 

Other 

613.448 

444.425 

(169.0231 

Total  Expenses 

2.372.669 

2.112.523 

(260.146) 

EXCESS  OF  REVENUES 

OVER  EXPENSES 

8 (231 .1821 

$ 86.577 

(317.759) 

Due  to  space  limitations,  notes  to  financial  statements  are  not  printed  here. 
Copies  are  available  through  the  LSMS  Membership  and  Finance  Department. 


Supplement  18  VOL  152  March  2000  J La  State  Med  Soc 


Council  on  Legislation 


During  the  1999  Regular  Session  of  the  Louisiana 
Legislature,  the  LSMS  achieved  an  overwhelming 
measure  of  success,  which,  in  great  part,  was  due 
to  the  very  effective  grassroots  effort  of  the  membership. 
You  are  to  be  congratulated  and  commended  for  your 
hard  work  and  devotion  to  the  practice  of  medicine,  which 
was  evidenced  by  your  countless  legislative  contacts. 
Special  thanks  to  all  physicians  who  either  came  to  Capitol 
to  support  LSMS  efforts  or  those  who  contacted  legislators 
at  their  district  offices  or  at  the  Capitol.  Without  such 
efforts,  our  success  could  not  have  been  achieved. 

The  LSMS  successfully  passed  81%  of  its  legislative 
priorities.  Most  importantly,  not  a single  piece  of 
legislation,  which  the  LSMS  actively  opposed,  was 
enacted  into  law.  Based  on  the  current  political  climate, 
these  are,  indeed,  remarkable  achievements,  of  which  the 
membership  should  be  exceedingly  proud. 

Our  contract  lobbyists,  Harris,  DeVille  and  Associates 
and  former  state  representative  Alphonse  Jackson,  were 
extremely  instrumental  in  our  success  this  session. 
Without  their  experience,  legislative  relationships,  and 
credibility,  we  would  not  have  been  able  to  defeat  such 
issues  as  psychology  prescribing,  physician  assistant 
prescribing,  childhood  immunization  schedule  changes, 
increases  in  the  medical  malpractice  cap  and  unwanted 
changes  to  the  Louisiana  State  Board  of  Medical 
Examiners.  In  addition,  our  contract  lobbyists  also  used 
their  considerable  talents  to  help  the  LSMS  pass  key 
legislation,  such  as  mental  health  parity. 


The  Louisiana  Psychiatric  Medical  Association's 
(LPMA)  contract  lobbyist,  Vera  Olds,  worked  diligently 
with  the  LSMS  to  defeat  the  psychology  prescribing  issue. 
After  a five-year  effort,  Ms.  Olds  also  helped  pass  a 
mandate  for  health  insurance  coverage  of  13  diagnoses 
of  severe  mental  illness.  The  coordinated  efforts  of  the 
DGA  staff,  the  LSMS  contract  lobbyists,  and  Ms.  Olds  were 
critical  to  our  success  on  these  two  priority  issues. 

The  Department  of  Governmental  Affairs  included  a 
"1999  Post  Legislative  Session  Survey"  in  the  1999 
Legislative  Summary,  which  was  mailed  to  the  entire 
membership  the  first  week  in  September.  The  Council  on 
Legislation  and  the  Department  of  Governmental  Affairs 
are  anxious  to  receive  and  review  the  results  from  the 
survey.  The  Council  on  Legislation  needs  to  hear  from 
the  membership  to  help  us  begin  to  plan,  prioritize,  and 
improve  our  overall  legislative  effort  for  the  next 
legislative  session.  The  information  gleaned  from  the 
survey  will  better  allow  the  LSMS  to  represent  and 
respond  to  medicine's  concerns  in  the  legislative  process. 

On  the  following  pages  is  a list  of  the  House  of 
Delegates  mandates,  which  required  action  by  the 
Department  of  Governmental  Affairs.  Along  with  each 
resolution  is  a description  of  the  action  taken  in  1999  and 
a recommendation  for  any  further  action. 

Charles  D.  Belleau,  MD 
Chair 


Council  on  Legislation 

Charles  D.  Belleau,  MD  .... 
William  J.  Daly,  Jr.,  MD  ... 

Robert  Normand,  MD 

Walter  H.  Daniels,  MD 

Rupert  G.  Madden,  MD 

Richard  I.  Ballard,  MD 

Michael  L.  Kudla,  MD 

Daniel  G.  Dupree,  MD 

Ralph  Maxwell,  III,  MD .... 


Sixth  District  and  Chair 

First  District 

Second  District 

Third  District 

Fourth  District 

Fifth  District 

Seventh  District 

Ninth  District 

Tenth  District 


Supplement  19  VOL  152  March  2000  J La  State  Med  Soc 


PART  I:  LEGISLATIVE  MANDATES  RENEWED 
BY  THE  HOUSE  OF  DELEGATE 

Resolution  203-93 

Limiting  Passive  Tobacco  Inhalation  in  Work  Places 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
support  and/or  seek  to  introduce  legislation  to  limit 
tobacco  smoking  to  specially  designated  areas  which,  by 
their  design  protect  non-smokers  from  exposure  to 
tobacco  smoke. 

RESOLVED,  that  the  Council  on  Legislation  develop 
a strategy  for  repealing  or  amending  the  "Smoker's 
Rights"  bills  of  1993  (Act  543  and  Act  571)  to  eliminate 
the  provisions  which  increase  exposure  of  non-smokers 
to  "passive"  tobacco  smoke,  and  to  introduce  or  support 
appropriate  legislation  to  accomplish  this  at  the  next 
"general"  legislative  session  of  the  legislature. 

1999  Implementation:  Supported  HB  1452  by  Rep. 
William  Daniel  and  SB  839  by  Senator  Jon  Johnson,  both 
of  which  sought  to  drastically  change  the  provisions  of 
the  "Smokers'  Rights"  legislation,  especially  the 
imposition  of  more  restrictive  local  ordinances  or 
regulations  related  to  smoking  in  public  places. 
Unfortunately,  neither  of  these  bills  passed. 

Recommendation  for  2000  Council  on  Legislation 
Action:  Retain  as  LSMS  policy,  abandon  as  legislative 
priority  and  support  anti-tobacco  legislation  if  introduced. 

Resolution  203-95 

Fair  Medicaid  Reimbursement  for  Health  Care 
Services  for  Children 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
seek  and/or  support  legislation  to  effect  fair  Medicaid 
reimbursement. 

1999  Implementation:  Supported  passage  and 
enactment  of  SB  256  (Act  1197  of  1999)  by  Senator  Hines 
and  HB  1 (Act  10  of  1999)  by  Rep.  LeBlanc,  the  General 
Appropriations  Bill,  to  increase  the  eligibility  and  funding 
of  the  Louisiana  Children's  Health  Insurance  Program 
(LaCHIP).  These  bills  expanded  LaCHIP  to  include 
families  with  incomes  up  150%  of  the  federal  poverty 
level;  this  second  phase  expansion  of  the  program  will 
cover  another  estimated  10,725  additional  children.  SB 
256  also  provides  authority  for  DHH  to  expand  Medicaid 
eligibility  for  those  children  in  the  same  age  range  after 
July  1,  2000  in  families  whose  income  does  not  exceed 
200%  of  the  FPL  under  LaCHIP,  provided  funding  and 
performance  standards  are  specifically  included  in  the 
General  Appropriations  Act  for  the  2000  Regular  Session. 

Recommendation  for  2000  Council  on  Legislation 
Action:  Support  continued  expansion  of  LaCHIP  to  full 
funding  and  continue  efforts  to  increase  reimbursement 
for  physician  services  in  the  Medicaid  program. 


Resolution  205-96 

Managed  Care  Consumer  Protection  Laws 

RESOLVED,  that  the  LSMS  work  with  the  Insurance 
Commissioner  and,  if  appropriate,  seek  or  support 
legislation  modeled  after  similar  legislation  in  Arizona, 
Minnesota  and  New  York,  to  require  insurance  companies, 
health  maintenance  organizations,  and  managed  care 
companies  to  file  for  public  review  with  the  Louisiana 
Insurance  Commissioner,  all  financial  incentives  and 
controls  in  physician  and  hospital  contracts  which,  when 
not  disclosed  may  limit  informed  choice,  and  further  be 
it 

RESOLVED,  that  these  insurers  disclose,  upon 
request,  to  employers,  patients  and  physicians,  the 
contractual  financial  incentives  and  controls  affecting 
patient's  access  to  health  care. 

1997  and  1999  Implementation:  Act  238  of  1997 
established  requirements  relative  to  quality  assurance, 
provider  contracting  and  disclosure,  grievance  procedures 
and  information  provided  to  subscribers,  enrollees  and 
providers.  Actively  participated  in  and  coordinated  the 
development  and  drafting  of  rules  and  health  care 
memoranda  with  the  Department  of  Insurance's  Office 
of  Health  Insurance  to  implement  the  goals  contained  in 
this  resolution  through  regulatory  implementation  of  the 
provisions  of  Act  238. 

Supported  passage  of  HB  2083  (Act  401  of  1999)  by 
Rep.  Ansardi,  which  establishes  requirements  relative  to 
medical  necessity  determinations  by  mandating  licensure 
of  medical  necessity  review  organizations  (MNROs).  This 
comprehensive  legislation  provides  for  internal  and 
external  appeal  procedures  and  provides  for  a cause  of 
action  against  an  MNRO  for  their  negligent  acts. 

Recommendation  for  2000  Council  on  Legislation 
Action:  Retain  as  policy,  but  abandon  as  legislative 
priority  and  continue  to  work  with  the  Department  of 
Insurance  to  achieve  additional  goals  through  regulatory 
implementation  of  existing  legislation. 

Resolution  206-96 

Reasonable  and  Customary  Fee  Schedule 

RESOLVED,  that  the  LSMS  seek  and/or  support 
legislation  to  require  insurers  to  file  reimbursement 
methodologies  with  the  Department  of  Insurance  and 
place  on  the  insured's  benefit  card  specific  information 
including,  but  not  limited  to,  co-pay  amount,  included 
plan  hospitals,  and  plan  differentiation  if  the  company 
has  more  than  one  product  in  the  area. 

1999  Implementation:  Supported  passage  of  HB  2052 
(Act  1017  of  1999)  by  Rep.  Thornhill  relative  to  standards 
for  timely  payment  of  health  insurance  and  managed  care 
enrollee  claims,  mandated  inclusion  on  the  insured  benefit 
card  certain  specific  information,  including  a toll  free 


Supplement  20  VOL  152  March  2000  J La  State  Med  Soc 


number  to  the  Department  of  Insurance's  consumer 
division  to  be  used  to  file  complaints  about  the  health  plan. 

Recommendation  for  2000  Council  on  Legislation 
Action:  Retain  as  policy,  but  abandon  as  legislative  priority 
and  continue  to  work  with  the  Department  of  Insurance 
to  achieve  additional  goals  through  regulatory 
implementation  of  Act  1017  and  other  existing  legislation. 

Resolution  208-96 

Fee  Schedules  in  Managed  Care  Organization 
Contracts 

RESOLVED,  that  the  LSMS  work  with  the  Insurance 
Commissioner  and,  if  appropriate,  seek  or  support 
legislation  with  the  purpose  of  requiring  that  contracts 
with  providers  must  specify  the  methodology,  including 
any  conversion  factors,  etc.,  to  result  in  a clear 
understanding  by  the  provider  of  expected  reimbursement 
for  services  rendered,  and  be  it  further 

RESOLVED,  that  the  LSMS  support  efforts  to  assure 
that  patients,  or  their  designee,  have  disclosed  upon  their 
request  the  exact  dollar  amounts  of  "allowed"  fees/ 
coverages,  when  considering  undergoing  medical  services 
that  may  result  in  an  obligation  for  a copayment  based  on 
those  coverage  amounts,  and  be  it  further 

RESOLVED,  that  the  LSMS  request  that  the  Insurance 
Commissioner  conduct  an  investigation  of  all  health 
insurance  companies  doing  business  in  Louisiana  for 
possible  violations  of  the  Louisiana  Insurance  Code 
Revised  Statutes  R.S.  22: 1214  "deceptive  acts  or  practices 
in  the  business  of  insurance"  which  appear  to  include  the 
unilateral  alteration  in  reimbursement  for  services,  without 
the  contractually  required  notification  to  the  other  contract 
party,  the  providers  of  those  services,  and  be  it  further 
RESOLVED,  that  the  LSMS  American  Medical 
Association  delegation  submit  a resolution  expressing  the 
following  to  the  next  AMA  meeting: 

1.  that  the  AMA  study  the  legal  appropriateness  of 
insurers  refusing  to  provide  the  most  basic  component 
of  a contractual  arrangement,  which  is  the 
reimbursement  to  the  provider  for  contracted  services, 
and,  if  deemed  inappropriate,  determine  what  legal 
remedies  may  be  implemented /legislated  to  prevent 
such  actions,  and  report  its  findings  to  the  1997  Annual 
Meeting,  and 

2.  that  the  AMA  study  and  report  at  the  1997  Annual 
Meeting  on  the  legal  appropriateness  of  unilateral 
alterations  in  contracts  without  appropriate 
notification  to  affected  parties,  and  what  legal  remedies 
can  be  implemented /legislated  to  prevent  such 
actions. 

1999  Implementation:  First  and  second  resolves: 
Supported  development  of  the  Department  of  Insurance's 
Office  of  Health  Insurance  Regulation  62  and  other 
regulations  requiring  such  reimbursement  methodology7 


and  other  disclosures.  Third  resolve:  Requested  more 
extensive  review  by  DOI's  Legal  Office  and  Office  of 
Health  Insurance  relative  to  health  insurance  contracts 
and  complaints  regarding  unilateral  alteration  in 
physician  reimbursement.  Fourth  resolve:  The 

jurisdiction  of  the  LSMS  AMA  delegation. 

Recommendation  for  2000  Council  on  Legislation 
Action:  Continued  participation  in  DOI's  Office  of  Health 
Insurance's  development  of  regulatory  mechanisms  in 
furtherance  of  these  goals. 

Resolution  210-96 

Voluntary  Health  Insurance  Purchasing  Co-Op 

RESOLVED,  that  the  LSMS  seek  and/or  support 
legislation  to  establish  a health  insurance  co-op  to  improve 
access  to  insurance  for  small  business  employees. 

1999  Implementation:  Supported  passage  of  HB 1183 
(Act  294  of  1999)  by  Rep.  Thompson,  which  authorizes 
the  Department  of  Insurance  to  develop  pilot  health 
insurance  programs  for  small  employers  and  for 
individuals. 

Recommendation  for  2000  Council  on  Legislation 
Action:  Continuation  of  cooperation  with  the  Department 
of  Insurance  in  its  developing  of  purchasing  cooperatives 
for  association  plans  using  multiple  insurers  and  health 
marts  under  Act  249  and  other  existing  legislative 
authority. 

Resolution  211-96 
Gag  Clauses 

RESOLVED,  that  the  LSMS  seek  and/or  support 
legislation  that  would,  in  the  absence  of  duplicate  federal 
law,  prohibit  managed  care  companies  from  imposing  any 
form  of  "gag  clause"  that  prevents  a physician  from 
discussing  quality  of  care  issues  and  treatment  options 
with  their  patients,  and  be  it  further 

RESOLVED,  that  the  LSMS  seek  and/or  support 
legislation  that  would  prohibit  managed  care  companies 
from  terminating  physicians  "without  cause"  and  provide 
physician  applicants  with  all  reasons  for  denial  of  an 
application  or  renewal  of  a contract.  A due  process  appeal 
containing  the  precise  mechanism  outlined  in  the  Health 
Care  Quality  Improvement  Act  of  1986  must  be  accorded. 

1999  Implementation:  First  resolve  achieved:  Act 
1232  of  1997  prohibits  "gag  clauses"  in  managed  care 
contracts,  including  development  of  regulatory 
mechanism  with  Department  of  Insurance  to  enforce 
prohibition.  Second  resolve:  As  concluded  by  the 
breakout  panel  specific  to  this  topic  at  the  1998  LSMS 
Managed  Care  Summit  and  subsequent  discussion  at  the 
LSMS  Managed  Care  Committee,  legislative 
implementation  of  this  mandate  was  not  pursued. 

Recommendation  for  2000  Council  on  Legislation 
Action:  Retain  as  LSMS  policy,  but  abandon  as  legislative 


Supplement  21  VOL  152  March  2000  J La  State  Med  Soc 


priority  pending  voluntary  efforts  of  working  with  the 
Louisiana  Managed  Healthcare  Association  and  the 
Louisiana  Business  Group  on  Health  through  the 
Department  of  Insurance. 

Resolution  212-96 
Insurance  Summary  Statement 

RESOLVED,  that  the  LSMS  work  with  the  Insurance 
Commissioner  and,  if  remedies  are  not  forthcoming,  seek 
and/or  support  legislation  that  would  require  every 
insurance  company  selling  health  insurance  in  Louisiana 
to  include  a single  front  page  in  bold  face  type  that 
explicitly  details  all  limitations  in  choice  of  primary  care 
physician,  in  access  to  specialists,  in  physician 
reimbursement,  and  in  regard  to  pre-existing  conditions. 

1999  Implementation:  Department  of  Insurance  rule 
promulgation  of  1999  enacted  legislation  pending. 

Recommendation  for  2000  Council  on  Legislation 
Action:  Pursue  development  and  review  of  rule  language 
during  DOFs  promulgation. 

Resolution  225-96 

Coroner’s  Report  to  Attending  Physicians 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
work  with  the  Louisiana  State  Coroners  Association  and, 
if  necessary,  to  seek  or  support  legislation  to  require  a 
coroner  in  a case  of  death  with  medical  attendance  to 
furnish,  upon  request,  the  coroner's  findings  based  on 
that  office's  examination,  investigation,  or  autopsy  to  the 
attending  physician. 

1999  Implementation:  Introduced  and  supported 
enactment  of  SB  581  (Act  761  of  1999)  by  Senator  Thomas, 
which  provides  that  a coroner  shall  furnish  a copy  of  his 
final  report  or  autopsy  report  to  the  deceased's  physician 
upon  request. 

Recommendation  for  2000  Council  on  Legislation 
Action:  None 

Resolution  202-97 

Operating  Standards  for  Companies  Managing  Health 
Care  In  Louisiana 

RESOLVED  that  the  LSMS  continue  to  support 
legislation  which  expands  the  minimum  operating 
standards  for  managed  care  companies  defined  in 
Louisiana  Legislative  Act  238. 

1999  Implementation:  Supported  provisions  in  HB 
2052  and  HB  2083.  (See  above) 

Recommendation  for  2000  Council  on  Legislation 
Action:  Continue  multi-faceted  approach  to  increase 
minimum  standards,  including  participation  in  the 
Department  of  Insurance  annual  Health  Care  Conference 
and  the  development  of  DOI's  issuance  of  health  care 
insurance  regulations  to  implement  existing  legislation. 


Resolution  203-97 

Regulation  of  Companies  Managing  Health  Care  in 
Louisiana 

RESOLVED,  that  the  LSMS  seek  and/or  support 
legislation  or  regulation  which  would  require  all  managed 
healthcare  companies  in  Louisiana  to  be  regulated  by  the 
same  laws  and  standards  which  regulate  health  insurance 
companies  except  for  different  solvency  standards  for 
provider  sponsored  organizations  as  established  by  the 
state  insurance  commissioner  and  / or  state  law,  and  be  it 
further 

RESOLVED,  that  the  LSMS  strongly  supports  the 
AMA's  efforts  to  change  ERISA  laws  that  exempt  self- 
insured  plans  from  state  laws  or  regulations. 

1999  Implementation:  First  resolve:  Worked  and 
continue  to  cooperate  with  the  Department  of  Insurance's 
Office  of  Health  Insurance  to  achieve  this  uniformity  and 
common  goal.  Second  resolve:  The  LSMS  communicated 
such  support  to  the  Louisiana  Congressional  Delegation 
and  at  AM  A meetings. 

Recommendation  for  2000  Council  on  Legislation 
Action:  Pursue  ongoing  strategy  to  achieve 

implementation. 

Resolution  205-97 

Settlement  of  Claims  for  Health  Care  Services 

RESOLVED,  that  the  LSMS  seek  and/or  support 
legislation  or  regulation  which  addresses  specific  penalties 
for  delayed  settlement  of  claims  for  payment  for  health 
care  services. 

1999  Implementation:  Supported  enactment  of  HB 
2052  by  Rep.  Thornhill,  provides  for  timely  payment  of 
health  insurance  claims. 

Recommendation  for  2000  Council  on  Legislation 
Action:  Work  with  the  Department  of  Insurance  to 
implement  through  rules  and  regulations  HB  2052  (Act 
1017  of  1999). 

Resolution  208-97 

Determining  Patient  Eligibility  for  Medical  Services 

RESOLVED,  that  the  LSMS  seek  and/or  support 
legislation  that  would  require  all  managed  health  care 
companies  in  Louisiana  to  provide  reasonable  and 
adequate  24  hour  a day  access  to  determine  eligibility  of 
patients,  names  of  approved  network  hospitals  and  names 
of  approved  physicians,  and  be  it  further 

RESOLVED,  that  such  legislation  will  also  declare  that 
if  patient  eligibility  information  is  not  readily  available,  it 
can  be  assumed  that  a patient  with  a managed  care 
identification  card  is  eligible  for  services  at  the  facility  to 
which  he/ she  has  presented,  and  be  it  further 

RESOLVED,  that  such  legislation  will  also  declare  that 
managed  health  care  companies  will  be  required  to  pay 
for  any  appropriate  services  rendered  to  patients  when 
hospitals  or  doctors  have  made  reasonable  efforts  to 


Supplement  22  VOL  152  March  2000  J La  State  Med  Soc 


determine  eligibility. 

1999  Implementation:  First  Resolve:  Supported 
enactment  of  HB  2083  by  Rep.  Ansardi,  which  provides 
for  licensure  and  standards  for  medical  necessity  review 
organizations.  Second  Resolve:  Urged  development  of 
DOI  Office  of  Health  Insurance  regulations  to  address 
these  issues  under  authority  of  HB  2083  (Act  401  of  1999). 

Recommendation  for  2000  Council  on  Legislation 
Action:  Continued  lobbying  and  monitoring  of  the 
rulemaking  process  by  DOI. 

Resolution  210-97 
Child  Death  Review  Panel 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
seek  and/or  support  legislation  that  ensures  adequate 
funding  for  the  Child  Death  Review  Panel,  and  be  it  further 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
seek  and/or  support  legislation  that  mandates  state 
funding  for  and  access  to  the  services  of  Forensic 
Pathologists  where  necessary  for  the  death  scene 
investigation  and  autopsies  for  unexpected  deaths  in 
infants  and  children,  and  be  it  further 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
seek  and/or  support  legislation  that  ensures  appropriate 
and  timely  exchange  of  information  concerning  child 
deaths  between  medical,  social  services  and  law 
enforcement  agencies.  This  specifically  should  include  the 
amendment  of  Louisiana's  Children's  Code,  Article  615, 
so  that  the  Child  Death  Review  Panel  may  have  access  to 
the  Office  of  Community  Service  files  and 
recommendations,  and  be  it  further 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
seek  and  / or  support  legislation  that  would  establish  DHH 
regional  Child  Death  Review  Panels  in  order  to  expedite 
the  timely  investigation  of  unexpected  child  deaths. 

1999  Implementation:  Sought  adequate  funding 
levels  in  the  General  Appropriations  Bill  during  the 
session.  Supported  enactment  of  SB  308  by  Senator  Cox 
(Act  436  of  1999),  which  revised  the  membership  of  the 
State  Child  Death  Review  Panel  to  include  a forensic 
pathologist,  raised  the  age  for  review  of  unexpected  deaths 
to  14,  clarified  functions,  provided  for  confidentiality  and 
established  local  panels. 

Recommendation  for  2000  Council  on  Legislation 
Action:  Ongoing;  monitor  rule-making  pursuant  to  Act 
436  and  lobby  to  increase  funding. 

Resolution  215-97 
Enactment  of  HMO  Liability  Law 

RESOLVED,  that  the  LSMS  seek  and/or  support 
legislation  in  1999,  or  earlier  in  any  regular  or  special 
legislative  session  where  it  could  be  legally  introduced,  to 
adopt  an  HMO  (managed  care  organization)  liability  law 
similar  to  the  Texas  law  which  holds  managed  care 
organizations  responsible  for  the  consequences  of  their 


medical  and  administrative  decisions,  and  be  it  further 
RESOLVED,  that  if  the  ongoing  court  challenge  to  the 
Texas  law  results  in  a ruling  that  the  state  law  is  preempted 
by  ERISA  or,  for  some  other  reasons,  cannot  be  legally 
enacted  then  the  first  Resolve  in  this  resolution  will  not 
be  initiated  by  the  LSMS. 

1999  Implementation:  Introduced  and  supported 
passage  of  SB  805  by  Senator  Landry,  as  well  as  three  other 
managed  care  liability  bills:  SB  439  by  Senator  Cox,  SB 
971  by  Senator  Irons  and  HB  752  by  Rep.  Murray. 
Ultimately,  the  consensus  bill,  HB  2083  (Act  401  of  1999) 
by  Rep.  Ansardi,  was  enacted  into  law. 

Recommendation  for  2000  Council  on  Legislation 
Action:  Ongoing;  actively  participate  in  the  DOI's 
development  of  rules  to  clarify  the  liability  provisions  of 
Act  401. 

Resolution  217-97 

Professional  Immunity  for  Specialists  Seeing  Patients 
Referred  by  Free  Community  Health  Care  Clinics  in 
Their  Private  Offices 

RESOLVED,  that  the  LSMS  seek  and/or  support 
legislation  that  would  extend  the  same  immunity  granted 
in  Act  959  of  1997  for  physicians  rendering  services  in 
their  private  offices  without  compensation  to  patients 
referred  to  them  by  any  free  community  health  care  clinic 
in  the  State. 

1999  Implementation:  Introduced  and  supported 
passage  of  SB  507  by  Senator  Casanova  (Act  1351  of  1999), 
which  provides  a limitation  of  liability  to  health  care 
providers  rendering  gratuitous  services  in  their  private 
offices  through  referral  from  a free  clinic  or  a virtual  clinic. 

Recommendation  for  2000  Council  on  Legislation 
Action:  None 

Resolution  223-97 

Loss  of  a Chance  of  Survival;  Smith  v.  State,  676  So. 
2d  543  (La.1996) 

RESOLVED,  that  the  LSMS  seek  and  / or  support 
legislative  efforts  to  overrule  Smith  v.  State  676  So.  2d  543 
(La.1996).  (also  Hastings  v.  Baton  Rouge) 

1999  Implementation:  The  Council  on  Legislation, 
at  its  March  28,  1999  meeting,  voted  to  not  pursue  this 
legislative  mandate  at  this  time  as  it  would  be  in  direct 
conflict  with  LSMS  efforts  to  pass  a managed  care  liability 
law  in  response  to  Resolution  215-97. 

Recommendation  for  2000  Council  on  Legislation 
Action:  Abandon 

Resolution  225-97 

Certification  or  Recertification  of  Skilled  Care  or 
Therapy  Services 

RESOLVED,  that  LSMS  seek  and/or  support 
legislation  and  HCFA  policy  that  would  bar  any  physician, 
other  than  the  attending  physician  or  consulting 


Supplement  23  VOL  152  March  2000  J La  State  Med  Soc 


physician,  from  certifying  or  recertifying  either  skilled 
level  of  care  and/or  therapy  services,  except  in  an 
emergency. 

1999  Implementation:  Contacted  the  Louisiana 

Medical  Assistance  Program  (Medicaid)  and  DHH's  Legal 
Division  as  to  possible  regulatory  implementation  of  this 
resolution. 

Recommendation  for  2000  Council  on  Legislation 
Action:  Ongoing;  continued  contact  with  both 

Congressional  and  state  staff  to  research  legislative  or 
regulatory  solutions. 

Resolution  226-97 
Post  Claim  Audits 

RESOLVED,  that  LSMS  seek  regulatory  relief  from  the 
Insurance  Commissioner  to  require  all  post  claim  audits 
to  be  completed  within  90  days  of  the  payment  of  the 
claim,  and  failing  this,  that  LSMS  seek  and/or  support 
legislation  to  prevent  this  practice. 

1999  Implementation:  Supported  passage  of  HB  2052 
(Act  1017),  which  mandates  that  the  period  of  time  that 
an  insurance  issuer  requires  for  submission  of  a claim  from 
the  rendering  of  the  service  is  the  precise  time  frame  from 
the  payment  to  a provider  by  the  insurer  that  the  insurer 
may  audit  paid  claims. 

Recommendation  for  2000  Council  on  Legislation 
Action:  None 

Resolution  227-97 

Creation  of  an  Organized  Medical  Staff  Section  in 
Companies  that  Manage  Health  Care  in  Louisiana 

RESOLVED,  that  the  LSMS  initiate  efforts  to  work 
with  the  Commissioner  of  Insurance  to  seek  and/or 
support  legislation,  if  necessary,  to  require  the  inclusion 
of  an  organized  medical  staff  in  companies  that  manage 
health  care  in  Louisiana,  and  be  it  further 

RESOLVED,  that  the  LSMS  request  that  the  AMA 
establish,  as  a very  high  priority,  policy  which  states  that 
the  incorporation  of  an  organized  medical  staff  must  be  a 
standard  of  organizations  that  accredit  managed  health 
care  companies  in  the  United  States. 

1999  Implementation:  First  resolve:  Research  and 
discussions  with  the  DOI's  Office  of  Health  Insurance  for 
possible  implementation.  Second  resolve:  Jurisdiction 
of  the  LSMS  AMA  delegation. 

Recommendation  for  2000  Council  on  Legislation 
Action:  None;  abandon  as  both  practically  and  politically 
unfeasible. 

PART  II:  1998  HOUSE  OF  DELEGATES 

MANDATES 

Resolution  202-98 

Enactment  of  HMO  Liability  Law 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
proceed  to  seek  and/or  support  legislation  in  1999  that 


adopts  an  HMO  (managed  care  organization)  liability 
law. 

1999  Implementation:  See  Resolution  215-97  above. 

Recommendation  for  2000  Council  on  Legislation 
Action:  None 

Resolution  203-98 

Release  of  Autopsy  Report  to  Attending  Physician 

RESOLVED,  that  the  LSMS  adopt  as  policy  that 
coroner's  statements  and  autopsy  reports  are  considered 
an  integral  part  of  the  deceased  patient's  medical  record 
and  that  copies  should  be  provided  to  the  deceased 
patient's  family  designated  physicians  of  record,  and  be 
it  further 

RESOLVED,  that  the  LSMS  seed  and/or  support 
changes  to  La.  R.S.  33:1563  that  will  authorize  and  direct 
coroners  to  provide  to  the  deceased  patient's  family 
designate  physicians  of  record  a copy  of  the  coroner's  final 
statement  and  autopsy  report. 

1999  Implementation:  See  Resolution  225-96  above. 

Recommendation  for  2000  Council  on  Legislation 
Action:  None 

Resolution  205-98 

Individually  Owned  Health  Coverage  System 

RESOLVED,  that  the  LSMS  support  the  creation  of 
an  employee  based  health  coverage  system  which 
provides  freedom  of  choice  to  employees  and  their 
families  in  selecting  and  changing  healthcare  coverage, 
and  be  it  further 

RESOLVED,  that  the  LSMS  supports  the  elimination 
of  the  current  tax  bias  against  individually  owned  and 
individually  chosen  health  coverage  plans  and  supports 
federal-state  legislation  and  AMA  proposals /resolutions 
to  help  create  an  economic  market  for  family  owned  plans 
with  a fair  premium  rating  system  independent  of 
employer  or  government  mandates,  and  be  it  further 

RESOLVED,  that  the  LSMS  Board  of  Governors 
consider  advocating  the  One-by-One  Project  developed 
by  the  Johnson-Wyandolte  County  Medical  Society 
(Kansas)  as  a means  of  promoting  the  concept  of 
individual  ownership  of  health  insurance. 

1999  Implementation:  Second  Resolve:  See 

Resolution  210-96  above;  Third  Resolve:  Board  of 
Governors  consideration  and  action  required. 

Recommendation  for  2000  Council  on  Legislation 
Action:  Second  Resolve:  Ongoing  policy  and  support 
for  federal  or  state  legislation,  or  both,  to  implement  goal. 

Resolution  206-98 
Continuing  Medical  Education 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
adopt  policy  that  a minimum  number  of  mandatory  CME 
hours  over  a period  of  three  years  be  a condition  of 


Supplement  24  VOL  152  March  2000  J La  State  Med  Soc 


medical  licensure  in  Louisiana,  and  that  Louisiana  State 
Board  of  Medical  Examiners  have  responsibility  for 
establishing  and  recommending  the  minimum  standard 
of  mandatory  Continuing  Education  with  the  advice  of 
the  LSMS  Board  of  Governors. 

1999  Implementation:  Supported  enactment  of  SB 
593  (Act  661)  by  Senator  Schedler  which  authorizes  the 
LSBME  to  establish  continuing  education  requirements 
for  the  renewal  or  reinstatement  of  medical  licenses. 

Recommendation  for  2000  Council  on  Legislation 
Action:  None;  transfer  of  recommendation  of  minimum 
standards  for  mandatory  continuing  medical  education 
to  the  LSMS  Committee  on  Medical  Education. 

Resolution  207-98 

Full  Implementation  of  the  Louisiana  Children’s  Health 
Insurance  Program  (LaCHIP) 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
support  legislation  to  expand  Louisiana  Children's  Health 
Insurance  Program  to  serve  underserved  children  in 
families  with  income  up  to  200%  of  the  federal  poverty 
level,  including  development  of  a LaCHIP  private  Health 
Insurance  Model  as  well  as  or  in  place  of  Medicaid 
expansion,  and  be  it  further 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
continue  to  provide  input  to  the  state  agencies 
participating  in  Louisiana  Children's  Health  Insurance 
Program  to  ensure  that  the  benefits  available  to  LaCHIP 
recipients  are  consistent  with  Louisiana  State  Medical 
Society  policy  and  sound  medical  practice. 

1999  Implementation:  See  Resolution  203-95  above. 

Recommendation  for  2000  Council  on  Legislation 
Action:  Ongoing 

Resolution  210-98 

Access  to  Medical  History  and  Medical  Related 
Information  By  Court-Appointed  Examining  Physician 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
seek  and/or  support  legislation  to  amend  LA.  Code  of 
Evidence  Article  510  B.(2)(f)  and  (g)  to  allow  the  court- 
appointed  examining  physicians  in  a judicial  commitment 
proceeding  complete  access  to  the  patient's  complete 
medical  record  and  history  before  he  or  she  examines  such 
patient  and  makes  a determination  regarding  the  patient's 
mental  status. 

1999  Implementation:  Introduced  and  supported 
passage  of  SB  495  (Act  747)  by  Senator  Thomas. 

Recommendation  for  2000  Council  on  Legislation 
Action:  None 

Resolution  211-98 
Retroactive  Claims  Denials 

RESOLVED,  that  the  LSMS  seek  and/or  support 
regulations  or  legislation  which  would  establish  a statute 


of  limitations  of  twelve  months  for  previously  approved 
and  paid  claims  to  be  reconsidered  and  request  for  refund 
to  be  made  after  which  time  payments  are  final  and 
cannot  be  recouped  against  future  claims. 

1999  Implementation:  See  Resolution  226-97  above. 

Recommendation  for  2000  Council  on  Legislation 
Action:  None 

Resolution  212-98 

Osteoporosis  Screening  Legislation 

RESOLVED,  that  Louisiana  State  Medical  Society 
carefully  review  legislation  relative  to  osteoporosis 
screening  programs  and,  if  appropriate,  support  such 
legislation. 

1999  Implementation:  Monitored  enactment  of  SB  4 
(Act  64)  by  Senator  Bajoie,  which  requires  health  insurance 
policies  to  provide  coverage  for  bone  mass  measurement 
for  the  diagnosis  and  treatment  of  osteoporosis. 

Recommendation  for  2000  Council  on  Legislation 
Action:  None,  other  than  retain  as  policy. 

Resolution  213-98 

Medicaid  Reimbursement  to  Physicians  for  Care 
Provided  to  Hospitalized  Patients 

RESOLVED,  that  the  LSMS  seek  or  support  legislation 
that  includes  physicians  among  those  reimbursed  for 
uncompensated  care  when  care  is  provided  in  a hospital 
setting  and  the  hospital  is  eligible  for  uncompensated  care 
reimbursement. 

1999  Implementation:  Federal  law  and  / or  HCFArule 
controls  uncompensated  care;  ongoing  discussions  with 
Louisiana  Congressional  delegation  staff  about 
implementation  of  this  resolution. 

Recommendation  for  2000  Council  on  Legislation 
Action:  None;  transfer  authority  for  this  resolution  to 
the  Committee  on  Federal  Legislation. 

Resolution  214-98 

Medicaid  Reimbursement  to  Multiple  Physician 
Visits 

RESOLVED,  that  Louisiana  State  Medical  Society  seek 
and  / or  support  legislation  or  DHH  rule  modification  to 
allow  Medicaid  reimbursement  for  concurrent  care  by 
physicians  providing  care  to  a patient  on  a single  day, 
and  be  it  further 

RESOLVED,  that  the  LSMS  seek  and/or  support 
legislation  of  DHH  rule  modification  to  allow  Medicaid 
reimbursement  to  all  physicians  providing  care  to  patients 
for  all  medical  services  and  / or  office  visits  in  excess  of 
the  12  visit  per  calendar  year  limit. 

1999  Implementation:  Sought  increase  in  Medicaid 
funding  for  private  provider  services  to  accomplish  these 
goals;  unfortunately  the  LSMS  was  only  able  to  maintain 
current  reimbursement  level  reimbursement  level  from 


Supplement  25  VOL  152  March  2000  J La  State  Med  Soc 


last  fiscal  year  into  the  current  fiscal  year. 

Recommendation  for  2000  Council  on  Legislation 
Action:  Ongoing 

Resolution  215-98 
Funding  of  LaCH IP 

RESOLVED,  Louisiana  State  Medical  Society  seek 
and/ or  support  legislation  to  provide  full  matching  funds 
for  the  state  child  health  insurance  program  (LaCHIP). 

1999  Implementation:  See  Resolution  207-98  and  203- 
95  above. 

Recommendation  for  2000  Council  on  Legislation 
Action:  Ongoing 

Resolution  216-98 

Full  Disclosure  of  Medicare  HMO  Policies 

RESOLVED,  that  LSMS  support  regulations  which 
require  Medicare  HMOs  operating  in  Louisiana  to 
establish  "truth  in  selling"  policies  which  require  full 
disclosure  of  the  limitations  for  covered  services  and 
incentives  under  which  Medicare  HMOs  operate,  and  be 
it  further 

RESOLVED,  that  LSMS  support  regulations  which 
would  develop  a more  effective  system  to  identify  patients 
covered  under  Medicare  HMOs  prior  to  service  being 
rendered  by  a non-participating  physician  or  hospital,  and 
be  it  further 

RESOLVED,  that  the  LSMS  support  the  mandate  of 
completion  of  a mental  status  evaluation  to  ensure  that 
the  responsible  party  is  capable  of  understanding  the 
consequences  of  surrendering  traditional  Medicare 
insurance.  (Referred  to  the  Committee  on  Mental  Illness 
and  Substance  Abuse) 

1999  Implementation:  First  and  second  resolves 
discussed  with  the  Department  of  Insurance's  Office  of 
Health  Insurance  for  rule  and  regulation  development  and 
promulgation. 

Recommendation  for  2000  Council  on  Legislation 
Action:  Ongoing 

Resolution  219-98 

A Right  of  Action  for  Negligent  Institution  of  a 
Lawsuit 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
develop  a long-range  tort  reform  platform  to  include  a 
right  of  action  for  negligent  institution  and  prosecution 
of  a lawsuit. 

1999  Implementation:  Supported  HB  247  by  Rep. 
Fruge,  which  sought  to  curb  frivolous  lawsuits  by 
providing  for  the  recovery  of  expenses  of  litigation  by 
defendants  who  successfully  defend  lawsuits.  HB  247 
did  not  pass,  and  after  going  three-fourths  of  the  way 
through  the  legislative  process,  died  in  the  Senate. 

Recommendation  for  2000  Council  on  Legislation 
Action:  Ongoing 


Resolution  221-98 

Reform  of  the  Louisiana  Medicaid  Program 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
pursue,  through  appropriate  avenues,  including 
legislation,  if  necessary,  a major  reform  in  the  Medicaid 
program  of  Louisiana,  such  that  choice  and  individual 
ownership  of  policies  are  paramount,  and  be  it  further 

RESOLVED,  that  the  reform  of  the  Medicaid  program 
recommended  by  the  LSMS  include  the  principles 
contained  within  the  Access  to  Better  Care  plan  developed 
by  the  LSMS,  which  calls  for  the  privatization  of  the 
Louisiana  Medicaid  program,  and  the  "LSMS  White  Paper 
on  Health  System  Reform,"  (which  addresses  the 
"uncompensated"  component  of  the  Medicaid  program), 
and  be  it  further 

RESOLVED,  that  consideration  be  given  to  a private 
insurance  voucher  for  Medicaid  patients,  subsidized 
premiums  for  the  "working  poor"  ineligible  for  Medicaid, 
medical  savings  accounts,  and  an  expansion  of  the  state's 
"high  risk  pool"  insurance  plan  for  high  risk  patients,  and 
be  it  further 

RESOLVED,  that  the  privatized  Louisiana  Medicaid 
program  include  the  following  choices  for  patients: 
traditional  insurance  plans,  managed  care  plans  (HMO, 
PPO,  etc.),  benefit  payment  schedule  plans,  medical 
savings  accounts,  and  "purchasing  pools"  to  enable 
individuals  to  achieve  group  rate  premiums,  and  be  it 
further 

RESOLVED,  that  the  LSMS  work  with  our 
Congressional  representatives  to  obtain  changes  in  federal 
law  to  allow  for  the  tax  deductibility  of  personal 
expenditures  for  health  insurance,  similar  to  those 
provided  the  business  community  (perhaps  using 
Louisiana  as  a "pilot"  state  for  such  an  effort),  and  be  it 
further 

RESOLVED,  that  the  LSMS  seek  additional  funding 
sources  for  its  efforts  to  privatize  the  Medicaid  program, 
to  include  applying  for  grants  from  organizations  such 
as:  the  Heritage  Foundation,  the  Kaiser  Foundation,  the 
Urban  Institute,  the  Robert  Wood  Johnson  Foundation, 
etc.,  and  be  it  further 

RESOLVED,  that  the  LSMS  funding  of  the  first  year 
of  the  Medicaid  Privatization  Project  operation  be  limited 
to  $25,000  and  that  funding  be  reviewed  annually  by  the 
Board  of  Governors. 

1999  Implementation:  Supported  adoption  of  HCR 
94  by  Rep.  Copelin,  which  requires  the  House  and  Senate 
Health  and  Welfare  Committees  to  study  potential 
reforms  of  the  Medicaid  system. 

Recommendation  for  2000  Council  on  Legislation 
Action:  Ongoing 


Supplement  26  VOL  152  March  2000  J La  State  Med  Soc 


Resolution  223-98 

Emergency  Medical  Personnel  Licensing  Law 

RESOLVED,  that  the  Louisiana  State  Medical  Society  seek 
or  support  legislation  to  amend  the  appropriate 
provisions  of  LA  R.S.  40:1234  to  authorize  the  Louisiana 
State  Medical  Society  Disaster  and  EMS  Committee  to 
develop  and  establish  basic  guidelines  for  statewide  EMS 
protocols,  and  be  it  further 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
seek  or  support  legislation  to  amend  the  appropriate 
provisions  of  LA  R.S.  40:1234  to  provide  that  in  the  absence 
of  a parish  medical  society  available  to  approve 
emergency  protocols  that  the  Louisiana  State  Medical 
Society  shall  develop  a mechanism  to  select  another  parish 
medical  society  to  fulfill  the  requirements  of  LA  R.S. 
40:1234. 

1999  Implementation:  Introduced  and  supported 
passage  of  SB  789  (Act  427)  by  Senator  Thomas  to 
accomplish  these  two  goals. 

Recommendation  for  2000  Council  on  Legislation 
Action:  None 


AMA  Delegation 


It  is  with  great  pleasure  that  I am  able  to  give  to  you 
the  updates  of  the  last  two  meetings  of  the  AMA 
House  of  Delegates.  Your  elected  delegates  have 
continued  to  advocate  for  you  and  carry  forward  the 
policies  of  the  Louisiana  State  Medical  Society. 

SUMMARY  OF  THE  199™  AMA 
HOUSE  MEETING 

Ad  Hoc  Committee  on  Governance  Report 

The  House  adopted  the  report  largely  as  delivered,  with 
these  highlights: 

♦ The  goals  of  the  Strategic  Plan  should  become  an 
overarching  part  of  all  Board  and  Council  meetings, 
with  all  new  issues  and  emerging  issues  regularly 
measures  against  the  plan 

♦ AMA  Bylaws  will  be  amended  to:  include  a Chair 
and  Chair-elect  as  officers  to  the  Board,  each  limited 
to  a single  one-year  term,  with  the  Chair-elect 
automatically  succeeding  to  Chair;  preclude  the  Chair 
from  immediately  running  for  the  position  of 
President-elect;  provide  that  no  AMA  officer  or 
trustee  shall  be  eligible  to  serve  as  Executive  Vice 
President  within  three  years  of  leaving  office. 

♦ The  Speaker  and  the  President  should  establish  a 
committee  of  the  House  to  determine  the  structure 
of  compensation  and  to  establish  the  amount  of 
compensation  for  the  Board  of  Trustees  annually.  The 
committee  will  provide  an  informational  report 
annually  to  the  House. 

AMA  Ad  Hoc  Committee  Membership  Report 

The  committee  delivered  its  third  report  since  it  was 
established  at  the  1997  Interim  Meeting.  It  provided  13 
recommendations,  ranging  from  strategic  audits  of 
recruitment  and  retention  activities  to  changes  in  dues 
billing  structure.  In  general,  it  lays  out  a groundwork  for 
new  directions  and  solutions  to  membership  issues  for 
consideration  in  1999. 

Organ  Donation  Campaign 

The  AMA  launched  a major  national  campaign  to  raise 
awareness  for  the  need  for  organ  donors.  Based  on  the 
Texas  Medical  Association's  "Live  and  Then  Give" 
program,  the  initiative  includes  a video,  brochures  and 
other  educational  materials. 

Private  Sector  Advocacy 

The  AMA  has  launched  an  aggressive  and  urgent 


campaign  to  highlight  and  correct  the  excessive  power  of 
health  plans  and  others  who  are  pursuing  profits  at  the 
expense  of  patients  and  their  physicians.  The  AMA, 
working  collaboratively  with  the  Federation,  will  be  there 
to  empower  physicians  who  are  fighting  for  their  patients 
and  the  integrity  of  the  patient-physician  relationship.  Our 
strategies  include: 

♦ An  action  oriented  initiative  at  national  and  state 
levels  to  expose  and  eliminate  unfair  managed  care 
practices. 

♦ Use  of  multi-disciplinary  response  teams  to  provide 
immediate  and  visible  presence  in  crisis  situations 
where  patient  and  physician  rights  are  not  being 
respected. 

♦ Strengthening  the  negotiating  positions  of  all 
physicians  (self-employed,  employed,  residents) 
through  legal  collective  bargaining  options. 

♦ Leading  the  legislative  drive  for  market  reform. 

♦ Developing  and  distributing  tools  to  empower 
physicians  in  dealing  with  the  managed  care 
environment. 

Benefits  for  AMA  Members: 

♦ Representation  and  Advocacy-  with  the  private 
insurance  carriers,  attorneys  general,  insurance 
commissioners,  legislatures.  Congress,  HCFA  and  the 
courts. 

♦ Practical  Information-  Coping  with  managed  care 
issues,  physician  practice  management  bankruptcies, 
and  assistance  with  organized  networks. 

Reference  Committee  Highlights 

Committee  A 

Negotiated  rulemaking.  Adopted  BOT  Report  38,  calling 
on  the  Board  to  provide  an  update  to  the  House  at  the 
1999  Annual  Meeting  on  the  negotiated  rulemaking  for 
lab  tests  and  other  regulatory  and  legislative 
developments  in  the  administration  of  Medicare's  lab  tests 
benefit,  and  reaffirming  the  need  for  the  AMA  to  continue 
its  participation  in  the  negotiated  rulemaking  process. 
Y2K  readiness;  universal  insurance.  Adopted  Resolution 
122,  continuing  efforts  to  ensure  Y2K  readiness;  and 
Resolution  109,  calling  on  the  AMA  to  continue  its  high 
priority  efforts  to  provide  affordable  health  expense 
coverage  for  all  segments  of  the  uninsured. 

Committee  B 

Medicare  "Fraud  and  Abuse."  Adopted  BOT  Report  34 
which  recommends  that  the  AMA  expand  the  scope  of  its 


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fraud  and  abuse  advocacy  efforts,  including  asking  for 
congressional  intervention  to  halt  abuse  practices  and 
refocus  enforcement  activities  on  traditional  definitions 
of  fraud  rather  than  inadvertent  billing  errors. 

Private  Sector  Advocacy.  Adopted  BOT  Report  36  which 
outlines  the  ongoing  activities  of  the  AMA  in  aggressively 
advocating  in  the  private  and  public  sectors  to  level  the 
playing  field  between  physicians  and  health  care  players. 

Committee  C 

Clinical  research.  Adopted  Resolution  309,  calling  for 
enhancement  of  the  AMA's  longstanding  efforts  to  sustain 
clinical  research  base  by  the  creation  of  a prioritization 
process  to  focus  on  patient  and  community  needs. 
Teaching  professionalism  across  the  continuum  of 
medical  education.  Adopted  Resolution  318,  calling  for 
the  AMA  to  respond  to  the  distractions  of  the  current 
climate  of  medical  economics  with  a rededication  to  the 
concept  that  "professional  attitudes,  values,  and  behaviors 
should  form  an  integral  part  of  medical  education  across 
the  continuum  of  undergraduate,  and  continuing  medical 
education." 

Committee  D 

Health  care  needs  of  young  adults.  Adopted  Resolution 
423,  calling  for  the  AMA  to  evaluate  the  need  for  a national 
initiative  to  identify  and  meet  the  health  care  needs  of 
young  adults,  18  to  29. 

Violence  in  schools.  Adopted  Resolution  403  directing 
the  Council  on  Scientific  Affairs  to  study  the  issue  of 
violence  in  schools  and  the  efficacy  of  school-based 
violence  prevention  programs. 

Committee  E 

Dietary  Supplements.  Adopted  Substitute  Resolution 
513,  calling  for  the  AMA  to  work  with  the  FDA  to  educate 
physicians  and  patients  about  the  safety  and  efficacy  of 
herbal  remedies  and  dietary  supplements. 

Committee  F 

Strengthening  the  Federation  Adopted  CLRPD  Report 
4,  which  encourages  strategies  to  strengthen  the 
Federation  in  an  increasingly  competitive  environment 
for  organized  medicine.  Recommends  that  the  Speaker 
of  the  House  of  Delegates  and  Chair  of  the  Board  jointly 
appoint  a task  force  to  develop  a detailed  plan  to 
transform  the  Federation  to  achieve  the  goals  of  the 
Statement  of  Collaborative  intent. 

Committee  G 

Definitions  for  "screening"  and  "medical  necessity." 

Adopted  Council  on  Medical  Service  Report  13,  which 
provides  definitions  for  "screening"  and  "medical 
necessity"  that  augment  the  well-established  AMA  policy 
base  on  medical  review.  While  many  insurers  currently 


use  the  lowest  cost  among  their  criteria  for  these  terms, 
the  AMA  definitions  are  based  on  the  physician's  best 
judgement. 

PRO  Sixth  Scope  of  Work.  Adopted  Council  on  Medical 
Sendee  Repot  16  which  describes  the  punitive  orientation 
of  the  proposed  PRO  Sixth  Scope  of  Work  and 
recommends  modifying  and  updating  several  policies 
pertaining  to  previous  Scopes  and  eliminating  the 
proposed  Payment  Error  Prevention  Program  in  the  Sixth 
Scope  which  includes  a "bounty  hunter"  incentive  aspect. 

Committee  H 

Accreditation  standards.  Adopted  Resolution  808, 
stipulating  that  the  AMA  work  with  JCAHO,  HCFA,  state 
legislatures  regulating  agencies,  and  other  accrediting 
groups  to  ensure  that  there  are  no  conflicts  among 
standards  and  their  interpretation  and  that  work  to  ensure 
that  accreditation  remain  in  the  private  sector,  and  not 
become  a function  of  government. 

CPT  code  edits.  Adopted  BOT  Report  35,  which  explains 
the  recent  implementation  of  off-the-shelf  edits  of  CPT 
codes  by  HCFA.  The  report  recommends  that  the  AMA 
continue  to  support  the  activities  of  the  Correct  Coding 
Policy  Committee  (CCPC)  and  to  urge  HCFA  to  accept 
CCPC  recommendations  relating  to  the  code  edits.  The 
report  also  calls  on  the  AMA  to  advocate  for  appropriate 
use  of  CPT  codes  and  guidelines  to  protect  the  integrity 
of  CPT. 

E&M  Documentation  Guidelines.  Adopted  Substitute 
Resolution  804  in  lieu  of  seven  resolutions  on  fraud  and 
abuse  and  E&M  guidelines.  Also: 

♦ Adopted  a "clear  and  unambiguous"  statement  that 
America's  physicians  have  had  enough  of  unfair  fraud 
and  abuse  enforcement  and  will  not  stand  for 
harassment  by  auditors  or  false  accusations  of  abusive 
and  fraudulent  behavior. 

♦ Demand  major  changes  in  Medicare  payment  reviews 
and  well-designed  pilot  tests  of  any  new  E&M 
guidelines. 

♦ Instructed  the  Board  to  continue  technical  assistance 
to  HCFA  through  the  CPT  editorial  panel  to  produce 
simpler,  patient-centered , clinically  relevant,  and  non- 
intrusive  guidelines  (e.g.,  peer  review  of  statistical 
outliers). 

Constitution  and  Bylaws 

Representational  role  of  AMA  delegates.  Adopted 
Council  on  Constitution  and  Bylaws  Report  3,  specifying 
that  in  casting  their  votes,  delegates  consider  the 
perspectives  of  what  is  best  for  patients  and  quality 
medical  care. 

Physician-assisted  suicide/euthanasia.  Adopted 
Substitute  Resolution  5,  calling  for  the  AMA  to  strongly 
oppose  any  bill  to  legalize  physician-assisted  suicide  or 
euthanasia. 


Supplement  29  VOL  152  March  2000  J La  State  Med  Soc 


SUMMARY  OF  THE  200™  AMA 
HOUSE  MEETING 

Constitution  and  Bylaws 

Sale  of  health-related  products  from  physicians'  offices. 

Adopted  CEJA  Report  1 that  offers  ethical  guidelines  for 
physicians  who  sell  non-prescription,  health-related 
products  from  their  office. 

Cloning.  Adopted  CEJA  Report  2 setting  forth 
recommendations  on  the  ethics  of  human  cloning.  The 
council  said  physicians  should  not  participate  in  human 
cloning,  but  noted  the  need  for  more  discussion  on  the 
harms  and  benefits  of  cloning. 

Reference  Committee  Highlights 

Committee  A 

Health  insurance  reform.  Adopted  BOT  10.  CMS  5 and 
CMS  2,  reinforcing  strong  support  for  AMA's  health 
insurance  reform  proposal  for  individual  insurance.  CMS 
2 documents  the  AMA's  recent  efforts  to  expand  coverage 
for  the  uninsured. 

Medicare  pharmaceutical  debate.  Adopted  BOT  Report 
19,  calling  for  the  AMA  to  advocate  that  Medicare 
coverage  of  pharmaceuticals  should  be  addressed  in  the 
broader  context  of  transforming  Medicare  into  a fiscally 
solvent  program.  The  report  recommends  that  the 
Medicare  program  needs  to  be  reformed  before  any 
additional  benefits  are  added. 

Committee  B 

Fraud  and  Abuse.  Adopted  Resolution  202,  agreeing  that 
the  "bounty"  provisions  of  the  Health  Insurance 
Portability  and  Accountability  Act  of  1996  should  be 
repealed  , and  that  HCFA  should  be  forced  to  sharply 
distinguish  true  alleged  fraud  from  other  matters  that 
might  be  deemed  wasteful  or  in  error. 

DVA  non-physician  prescribing  authority. 
Acknowledged  the  hard  work  of  the  AMA,  in  cooperation 
with  state  medical  societies  and  national  medical  specialty 
societies,  in  forcing  the  Department  of  Veteran  Affairs  to 
retract  the  proposed  rule  that  would  have  permitted  non- 
physician health  care  professionals  to  prescribe 
medications. 

Disruptive  visits  to  medical  offices  be  government 
investigators  and  agents.  Adopted  Resolution  211, 
encouraging  the  AMA  to  support  legislation  or  other 
appropriate  means  to  prohibit  unannounced  visits  to 
physician  offices  by  government  investigators  and  agents. 

Committee  C 

State  authority  and  flexibility  in  medical  licensure  for 
telemedicine.  Adopted  CME  Report  7,  which 


recommends  amending  AMA  policy  to  call  for  medical 
licensing  boards  to  require  a full  unrestricted  license  to 
practice  telemedicine  in  that  state. 

Clinical  skills  assessment.  Adopted  CME  Report  5,  which 
recommends  a series  of  actions  to  assess  the  value  of 
existing  clinical  skills  assessment  examinations,  which 
support  for  a national  examination  to  test  clinical  skills. 
Hospitals  and  medical  education.  Adopted  CME  Report 
2,  which  recommends  that  the  AMA  collect  data  on  the 
emergence  of  educational  opportunities  for  hospitalist 
physicians  at  the  residency  level. 

Committee  D 

Cigar  smoking.  Adopted  resolution  433,  which  extends 
the  AMA's  considerable  anti-tobacco  policy  to  cover 
cigars. 

Action  on  states'  allocation  of  tobacco  settlement  money. 

Adopted  Resolution  428,  which  seeks  emphatic 
reaffirmation  of  AMA  support  for  tobacco  control. 
Encourages  lobbying  activities  and  initiatives  with  state 
and  specialty  societies,  and  requests  a report  to  be  given 
at  1-99. 

Immunization  registries.  Adopted  Resolution  415,  which 
encourages  physicians  to  participate  in  the  development 
and  use  of  immunization  registries  for  their  communities. 

Committee  E 

Drug  initiation  or  modification  by  pharmacists.  Adopted 
Resolution  509,  which  recommends  the  AMA  oppose 
pharmacists  being  given  the  authority  to  initiate  or  modify 
drug  treatment  except  on  a case  by  case  basis  at  the  specific 
direction  of  a physician. 

Prescription  of  schedule  II  medications.  Adopted  BOT 
report  8,  which  asks  that  the  AMA  encourage  the  DEA  to 
accommodate  encrypted  electronic  prescriptions  for 
Schedule  II  controlled  substances,  as  long  a sufficient 
security  measures  are  in  place  to  ensure  the  information's 
confidentiality  and  integrity. 

Stem  Cell  Research.  Adopted  Resolution  526,  calling  for 
the  AMA  to  encourage  strong  public  support  for  federal 
funding  involving  human  pluripotent  stem  cells. 

Committee  F 

AMA  vision  and  strategic  directions.  Adopted  BOT 
Report  24,  which  establishes  strategic  directions  for  the 
development  of  the  "AMA  Plan  for  the  Year  2000".  This 
document  includes  strategies  to  support  the  AMA's 
envisioned  future  as  the  medical  professions  leading  force 
in  solutions,  knowledge  and  tools  that  promote  health. 
Admission  of  professional  interest  medical  associations. 
Adopted  CLRPD  Report  1,  which  reflects  the  House's 
commitment  to  being  an  inclusive  body  that  is  responsive 
to  membership  concerns. 


Supplement  30  VOL  152  March  2000  J La  State  Med  Soc 


Committee  G 

Medicare  Review  Activities.  Adopted  CMS  Report  11, 
urging  HCFA  to  provide  physicians  with  the  opportunity 
for  significant  comment  and  input  in  the  development  of 
the  Medicare  Integrity  Program  (MIP),  and  opposing  the 
HCFA's  potential  use  of  a "bounty  system"  for  MIP  and 
incentives  or  "award  fees"  in  the  PRO  Sixth  Scope  of  Work. 
Utilization  and  preauthorization.  Adopted  Substitute 
Resolution  705,  calling  for  the  AMA  to  advocate  that 
utilization  efforts  focus  on  statistical  outliers,  rather  than 
blanket  review  of  whole  populations  of  physicians  or  all 
instances  of  particular  services;  and  that  the  AMA 
advocate  managed  care  plans  restrict  preauthorization 
requests  to  physicians  whose  claims  have  shown  to  be 
statistical  outliers. 

Managed  Care  Opt  Out  Rules.  Adopted  Resolution  707, 
which  calls  for  the  AMA  to  oppose  managed  care  "bait 
and  switch"  practices;  to  support  current  proposals  to 
extend  the  30  day  waiting  period  that  limits  when 
Medicare  recipients  may  opt  out  of  managed  care  plans. 

Committee  I 

National  Labor  Organization.  Ina  historic  vote. 
Committee  I recommended  that  the  AMA  should  develop 
an  affiliated  national  labor  organization  to  represent 
employed  physicians  and  where  allowed  by  law, 
residents.  The  House  of  Delegates  directed  the  formation 
of  a national  negotiating  organization  for  physicians.  This 
AMA  affiliated  but  separate  entity  will  offer  physicians 
an  alternative  to  traditional  unions  on  quality  of  care  and 
employment  issues.  This  organization  will  represent 
employed  physicians  and  eligible  resident  physicians  in 
collective  bargaining  with  their  employers  throughout  the 
United  States. 

The  national  negotiating  organization  will  be  a 
professional  organization  focusing  on  patient  advocacy 
and  faithful  to  the  AMA  Code  of  Medical  Ethics.  Driven 
by  local  invitation,  the  affiliate's  prime  mission  will  be  to 
respond  to  the  needs  of  local  physicians  and  their  patients. 
The  organization  will  be  developed  in  close  collaboration 
with  the  entire  Federation  of  Medicine,  and  will  not  be 
affiliated  with  traditional  organized  medicine. 

Physician  owned  and  operated  group  practices  will 
not  be  affected  by  this  activity.  When  representing 
residents,  the  organization  will  not  engage  in  bargaining 
on  academic  issues.  Physicians  represented  by  this 
organization  will  not  strike,  nor  endanger  patient  care. 
The  AMA' s Private  Sector  Advocacy  group  is  immediately 
implementing  this  House  of  Delegates  directive. 

W.  Juan  Watkins , MD 
Chair 


AMA  Delegation 

Delegates 

W.  Juan  Watkins,  MD  • Chair 
Milton  C.  Chapman,  MD 
Michael  S.  Ellis,  MD 
K.  Barton  Farris,  MD 
Jay  M.  Shames,  MD 

Alternates 

Carol  L.  Bayer,  MD 

Lawrence  L.  Braud,  MD 

Wallace  H.  Dunlap,  MD 

Dudley  M.  Stewart,  Jr.,  MD 

Joshua  E.  Lowentritt,  MD  • Resident 

Young  Physicians  Section 
Victor  Tedesco,  IV,  MD  • Delegate 
James  Baker,  MD  • Alternate 

AMA  Officials 

Donald  Palmisano,  MD  • Board  of  Trustees 
Daniel  H.  "Stormy"  Johnson,  Jr.,  MD  • Past  Presi- 
dent, 1997-98 


Dr.  Don  Palmisano  delivers  his  campaign 
speech  at  the  AMA  House  meeting. 


Supplement  31  VOL  152  March  2000  J La  State  Med  Soc 


LAMPAC 


It  is  with  great  pleasure  that  I write  this  report  advising 
you  of  the  current  status  of  LAMPAC!  First,  in  contrast 
to  last  year's  report,  I am  thrilled  to  inform  you  that 
we  currently  have  a total  membership  of  1,149.  This 
represents  an  increase  of  144  members  over  the  year-end 
total  for  1998. 

We  will  not  rest  on  our  laurels  and  will  continue  an 
aggressive  membership  campaign  for  the  rest  of  the  year. 
As  you  may  know,  LAMPAC' s membership  reached  an 
all  time  high  in  1987  with  a total  membership  of  1,558 
and,  prior  to  this  year,  has  been  in  decline  since.  We  are 
pleased  that  so  many  physicians  and  spouses  have 
recognized  the  importance  of  returning  LAMPAC  to  its 
prior  level  of  membership,  influence,  and  prominence.  In 
order  to  participate  in  the  election  process  as  a significant 
player,  it  is  imperative  that  we  now  embark  upon  a 
continuing  trend  of  increased  membership  in  LAMPAC. 

At  this  time,  LAMPAC  continues  to  be  the  third  largest 
PAC  in  the  state,  ranking  only  behind  the  Louisiana 
Association  of  Business  and  Industry  (LABI)  and 
Louisiana  Trial  Lawyers  Association  (LTLA).  This 
achievement  brings  great  pride  to  our  organization. 
However,  in  order  to  maintain  our  strong  political 
presence  we  must  strive  to  annually  increase  our  level  of 
funding.  Organized  medicine  could  be  perceived  as  weak 
and  disinterested  if  LAMPAC  were  to  decline  in  its 
funding  and  role  during  the  election  process. 

On  Sunday,  August  29, 1999,  the  LAMPAC  Board  met 
to  discuss  the  upcoming  fall  elections.  After  recommend- 


ations from  the  Department  of  Governmental  Affairs,  our 
contract  lobbyists,  and  individual  members  the  Board 
deliberated  and  approved  contributions  for  numerous 
legislative  and  statewide  races.  As  a result,  thus  far, 
LAMPAC  has  expended  a total  of  approximately  $184,000 
during  the  1999  fall  election  cycle.  Therefore,  the  LAMPAC 
"War  Chest"  is  being  depleted  at  a rapid  pace  and  needs 
replenishing.  I would  urge  each  member  of  the  House  of 
Delegates  to  become  a member  of  LAMPAC  and  take  an 
active  role  in  the  political  arena. 

LAMPAC's  success  rate  over  the  years  has  been  a 
solid  75%  in  the  races  it  has  participated  in  since  1987. 
LAMPAC  is  highly  regarded  as  an  effective  player  in 
major  statewide  races,  as  well  as  congressional  races. 
LAMPAC  strives  to  support  pro-medicine  candidates  who 
will  protect  organized  medicine  and  needs  physicians  and 
alliance  members  who  will  help  voice  their  concerns  to 
all  elected  officials. 

Again,  I cannot  over  emphasize  the  importance  of  all 
LSMS  physicians  making  a commitment  to  develop  and 
maintain  LAMPAC  beyond  its  present  level.  We  have  an 
opportunity  to  stand  together  and  make  a united  effort 
to  influence  the  course  of  medicine. 


I he  slakes  are  too  high  tor 
government  to  he  a spectator  sport. 
Barbara  Jordan 


Wallace  H.  Dunlap , MD 
Chair 


LAMPAC  Board  of  Directors 

Wallace  H.  Dunlap,  MD,  Chairman 

Merlin  H.  Allen,  MD 

Richard  M.  Lauve,  MD,  Vice-Chairman 

James  B.  Aiken,  MD 

William  Cassidy,  MD,  Treasurer 

Daniel  I.  Caplan,  MD 

Lorre  Lei  Jackson,  Secretary 

Stephen  E.  Heilman,  MD 

Robert  L.  diBenedetto,  MD 

William  Hall,  MD 

Howard  A.  Nelson,  Jr.,  MD 

James  S.  Finley,  III,  MD 

Harris  Blackman,  MD 

David  G.  Fourrier,  MD 

Walter  H.  Daniels,  MD 

Eli  Sorkow,  MD 

F.  Jeff  White,  III,  MD 

Melanie  C.  Firmin,  MD 

Herschel  R.  Harter,  MD 

Brian  W.  Amy,  MD 

Michael  L.  Kudla,  MD 

Frank  P.  Robinson,  III,  MD 

J.  Russ  Marrazzo,  III,  MD 

Connie  Boyer 

Paul  J.  Azar,  Jr.,  MD 

Supplement  32  VOL  152  March  2000  J La  State  Med  Soc 


ERF 


T 


he  Educational  and  Research  Foundation  activities 
revolved  around  three  general  areas  in  1999,  and 
they  are  as  follows: 


Philip  H.  Jones,  MD,  Memorial  Scholarship  Fund 

The  Philip  H Jones,  MD,  Memorial  Scholarship  Fund  was 
named  after  Philip  H.  Jones,  MD,  whose  estate  provided 
a donation  for  the  initial  establishment  of  the  scholarship 
program.  The  purpose  of  the  program  is  to  award 
scholarships  to  exceptionally  qualified  but  financially 
needy  medical  students  from  Louisiana. 

During  1999  the  Board  of  Directors  allocated  $4,000  to 
be  given  to  each  of  the  three  medical  schools  in  Louisiana 
to  award  $1000  scholarships  to  four  students  at  each 
school.  The  medical  schools  will  identify  the  students  to 
receive  the  funds  based  on  the  criteria  established  by  the 
Board  and  notify  the  ERF  of  the  selections. 

The  ERF  is  investigating  new  ways  to  generate  money 
to  increase  this  fund  in  order  to  provide  additional  support 
for  worthy  students. 

The  ERF  would  like  to  thank  all  of  those  members  who 
served  on  the  Philip  H.  Jones,  MD,  Scholarship  Committee 
over  the  past  28  years.  These  physicians  reviewed  many 
applications  and  interviewed  hundreds  of  students  before 


ippl 

:hoo 


choosing  the  students  each  year  to  receive  scholarships. 
They  did  a remarkable  job  of  being  able  to  pick  the  most 
worthy  candidates. 


Educational  and  Research  Foundation 
Board  of  Directors 

Charles  D.  Belleau,  MD 
Joseph  Busby,  MD 
Vincent  Cullotta,  MD 
Martin  J.  Ducote,  Jr.,  MD 
K.  Barton  Farris,  MD 
William  T.  Hall,  MD 
Barry  G.  Landry,  MD 
Leo  L.  Lowentritt,  Jr.,  MD 
Russell  C.  Klein,  MD 
Richard  J.  Paddock,  MD 
Marcus  L.  Pittman,  III,  MD 
Dudley  M.  Stewart,  Jr.,  MD 
Martin  B.  Tanner,  MD 
Lynn  Z.  Tucker,  MD 
R.  Mark  Williams,  MD 


Medical  Student  and  Resident  Section  Support 

Every  year  the  ERF  provides  designated  funding  to  the 
LSMS  Medical  Student  Section  and  the  LSMS  Resident 
Section.  This  funding  enables  these  sections  to  send 
representatives  to  the  annual  and  interim  meetings  of  the 
American  Medical  Association. 

Educational  Activities 

The  Committee  on  Continuing  Medical  Education  was 
established  to  enable  the  ERF  to  become  an  accredited 
provider  of  AMA  Category  1 and  2 CME  credits  and  has 
been  accredited  to  do  so  since  1992.  The  CME  Program 
was  reaccredited  in  1998  for  four  more  years. 

Since  one  of  the  primary  goals  of  the  CME  Program 
is  to  jointly-sponsor  CME  activities  with  non-accredited 
entities,  the  ERF  CMEP  jointly-sponsored  several  CME 
activities  this  year  with  hospitals,  specialty  societies, 
component  medical  societies  and  other  organizations.  We 
also  sponsored  the  1999  LSMS  Leadership  Conference.  The 
role  of  the  ERF  CME  Program  has  greatly  expanded  in  the 
past  three  years  and  we  foresee  that  it  will  continue  to 
grow  so  that  physicians  can  obtain  CME  credit  without 
having  to  travel  great  distances  to  do  so. 


Michael  S.  Ellis , MD 
President 
Dudley  M.  Stewart , Jr.,  MD 
Vice  President 
Wallace  H.  Dunlap,  MD 
Secret  ary /Treasurer 


Committee  on 

Continuing  Medical  Education 

Russell  Klein,  MD,  Chair 
Bettina  C.  Hilman,  MD 
Sharda  Kumar,  MD 
Larry  E.  Millikan,  MD 
Raghunath  P.  Misra,  MD 
Wallace  Rubin,  MD 
Gregory  Stewart,  MD 
Eli  Sorkow,  MD 
Watts  R.  Webb,  MD 


Supplement  33  VOL  152  March  2000  J La  State  Med  Soc 


nun 

rnrL 

The  Physicians  Health  Foundation  was  formed  in 
1998  per  the  House  of  Delegates  Resolution  119-97. 
The  Board  of  Trustees  of  the  Foundation  was 
composed  of  eight  physicians  elected  from  the  Board  of 
Governors  of  LSMS  and  five  physicians  from  the 
Physicians  Health  Committee.  The  structure  and  bylaws 
were  formulated  in  December,  1998,  and  approved  by  the 
Board  of  Trustees. 

A great  deal  has  been  accomplished  this  year  with  the 
superb  assistance  of  Michael  DeCaire,  Administrative 
Director,  and  Amy  W.  Phillips,  J.D.,  Director  of  Legal 
Affairs  and  General  Counsel  of  LSMS.  A new  drug  testing 
program  has  been  initiated  which  will  aid  the  Foundation 
in  monitoring  and  advocating  for  physicians  enrolled  in 
the  program.  Michael  DeCaire  has  met  with  component 
societies  and  hospitals  throughout  the  state  to  familiarize 
them  with  the  program.  The  process  of  identification  and 
intervention  of  involved  physicians  has  been  streamlined. 
The  Foundation  is  ready  to  quickly  aid  any  physician  with 
the  new  program. 


The  Foundation  has  maintained  a good  working 
relationship  with  the  Louisiana  State  Board  of  Medical 
Examiners.  Revision  of  the  Memorandum  of 
Understanding  (which  allows  the  Foundation  to  work  with 
the  LSBME)  is  in  progress.  A confidential  data  base  has 
been  established  to  more  closely  monitor  physicians  in 
recovery.  This  will  give  the  Foundation  the  information 
needed  to  modify  the  Physicians  Health  Program  to  help 
its  participants.  Outside  sources  of  funding  have  been 
identified,  and  the  Foundation  hopes  to  soon  be  self- 
sufficient. 

This  has  been  an  exciting  and  busy  year.  Thanks  to 
the  gracious  support  of  the  LSMS,  its  Board  of  Governors, 
and  physician  members,  that  physicians  and  patients  of 
Louisiana  can  be  helped. 

Michael  L.  Kudla,  MD 
President 


Board  of  Trustees 
(Board  of  Governors) 


D.  Richard  Davis,  II,  MD,  Secretary 
Lynn  Z.  Tucker,  MD,  Treasurer 
Joseph  D.  Busby,  Jr,  MD 
Aris  Wl.  Cox,  MD 
Martin  J.  Ducote,  Jr.,  MD 
William  T.  Hall,  MD 
Barry  G.  Landry,  MD 
Bruce  Steigner,  MD 
Dudley  M.  Stewart,  Jr,  MD 
Martin  Tanner,  MD 
Ronald  Taravella,  MD 
R.  Mark  Williams,  MD 


(Physicians’  Health  Committee) 

Michael  Kudla,  MD,  Chair 
Martha  E.  Brown,  MD,  Medical  Director 
Patrick  Mottram,  MD,  District  1 Representative 
Bennie  P.  Nobles,  Jr.,  MD,  District  2 Representative 
J.  Bruce  Steigner,  MD,  District  3 Representative 
D.  Richard  Davis,  II,  MD,  District  4 Representative 
Aris  W.  Cox,  MD,  District  5 Representative 
Ronald  Taravella,  MD,  District  6 Representative 
Ronald  M.  Lewis,  MD,  District  7 Representative 
William  A.  Bernard,  MD,  District  9 Representative 
Ralph  Maxwell,  III,  MD,  District  10  Representative 
Jerry  R.  Hasking,  MD,  District  1 Alternate  Representative 
Louis  J.  Sardenga,  MD,  District  4 Alternate  Representative 
Thomas  Colvin,  MD,  District  5 Alternate  Representative 
Jeanne  M.  Estes,  MD,  District  6 Alternate  Representative 
Bryan  C.  McCann,  MD,  District  8 Alternate  Representative 


Supplement  34  VOL  152  March  2000  J La  State  Med  Soc 


Departmental  Reports 


EXECUTIVE  DEPARTMENT 

Once  again,  1999  proved  to  be  a very  active  year  in  the 
LSMS  which  saw  the  LSMS  engaged  in  a wide  variety  of 
projects  and  activities  on  behalf  of  its  membership  and 
the  patients  they  serve.  As  medicine  changes,  so  must  the 
LSMS.  Following  are  some  of  the  major  projects  and  issues 
dealt  with  during  the  past  year. 

1999  Legislative  Effort 

On  Tuesday,  April  13,  1999  the  LSMS  hosted  a Legislative 
Reception  for  members  of  the  Louisiana  Legislature  and 
their  guests  at  Desiree's  Restaurant  in  Baton  Rouge. 
Attended  by  legislators,  legislative  staff,  and  LSMS  and 
component  society  leaders  from  around  the  state,  the  event 
was  the  first  of  what  will  be  an  annual  reception  at  the 
beginning  of  the  session. 

During  the  85-day  legislative  session  the  LSMS 
achieved  a remarkable  degree  of  success,  thanks  in  great 
part  to  the  effective  grassroots  effort  of  LSMS  members. 
Much  of  the  legislation  the  LSMS  supported  was  passed 
while  none  of  the  legislation  the  Society  actively  opposed 
was  signed  into  law.  The  LSMS  maintained  an  extremely 
active  presence  at  the  Capitol  this  year  lobbying  tirelessly 
and  establishing  valuable  relations  with  a number  of 
political  groups.  The  LSMS  utilized  its  website  to  keep 
the  membership  informed  of  legislative  action  by 
publishing  a weekly  summary  of  key  bills  heard  and  those 
due  to  be  considered  the  following  week.  The  LSMS  made 
extensive  use  of  its  blast  email  and  fax  capability  to  alert 
members  when  phone  calls  and  letters  were  needed  to  area 
legislators. 

One  major  area  of  success  involved  legislation 
governing  insurance  and  managed  care  companies.  The 
LSMS,  working  with  the  Department  of  Insurance,  was 
successful  in  passing  legislation  mandating  timely 
payments  of  claims  and  licensure,  standards  and  liability 
of  organizations  making  medical  necessity  decisions, 
including  a patient's  right  to  sue  a managed  care  entity 
for  negligence  relating  to  medical  necessity  decisions. 
Working  with  a coalition  composed  of  the  Louisiana 
Chapter  of  NAMI,  the  Louisiana  Psychiatric  Medical 
Association,  the  Louisiana  Chapter  of  the  National 
Association  of  Social  Workers,  and  the  Louisiana 
Counseling  Association,  the  LSMS  also  supported  a bill 
by  Representative  Donelon  which  mandated  insurance 
coverage  for  13  of  the  most  severe  mental  illnesses.  Against 
strong  opposition  to  such  coverage,  the  bill  passed  and 
became  Act  1285  of  1999. 

There  was  a strong  move  in  the  legislature  to  change 


the  composition  of  the  Louisiana  State  Board  of  Medical 
Examiners  by  allowing  a hospital  medical  director  and  a 
non-voting  APRN  to  sit  on  the  Board.  The  LSMS  opposed 
these  provisions  and  succeeded  in  having  them  removed. 
The  House  bill  also  provided  for  staggered  terms  and  term 
limits.  As  passed,  beginning  in  January  2000,  the  Board 
will  consist  of  seven  members:  four  physicians  selected 
from  a list  of  names  submitted  by  the  LSMS,  two 
physicians  selected  from  a list  submitted  by  the  Louisiana 
Medical  Association,  and  one  physician  selected  from  a 
list  submitted  by  the  Louisiana  Academy  of  Family 
Physicians.  Terms  now  are  for  four  years  with  a maximum 
of  three  terms. 

The  LSMS  was  successful  in  opposing  an  effort  to  cut 
the  proposed  Medicaid  budget  which  would  have  resulted 
in  private  physicians  seeing  another  significant  reduction 
in  reimbursement.  The  LSMS  lobbied  to  maintain  the 
current  levels  of  reimbursement  for  FY  1999-2000.  To 
balance  the  budget  the  Legislature  appropriated  a portion 
of  the  proceeds  from  the  Tobacco  Settlement  to  maintain 
current  funding  levels. 

Several  bills  were  introduced  which  sought  to  raise  or 
entirely  remove  the  cap  on  medical  malpractice  cases.  The 
LSMS  was  successful  in  seeing  that  none  of  these  bills 
passed  both  houses.  However,  an  effort  to  pass  several 
needed  administrative  and  operational  changes  to  the 
Patients  Compensation  Fund  was  not  successful.  One 
proposed  bill,  SB  877,  could  have  saved  the  Fund 
approximately  $3,174,000  per  year.  But  on  the  request  of 
an  administration  floor  leader,  it  was  returned  to  the 
calendar  and  died  upon  adjournment  of  the  legislature. 

Several  paramedical  groups  introduced  bills  to  expand 
their  scope  of  practice  including  psychologists,  physician 
assistants,  and  hypnotherapists.  Two  major  efforts  were 
involved  in  defeating  bills  that  would  allow  psychologists 
and  physician  assistants  to  prescribe  medications.  A House 
bill  covering  physician  assistants  was  defeated  on  the  floor 
when  it  was  involuntarily  returned  to  the  calendar. 
Working  closely  with  the  LA  Psychiatric  Medical 
Association,  we  were  able  to  ultimately  defeat  two  bills 
which  were  moving  simultaneously  through  both 
chambers  of  the  Legislature.  Details  on  the  legislative 
action  involving  these  bills  can  be  found  under  the  report 
of  the  Council  on  Legislation.  The  LSMS  successfully 
opposed  the  creation  of  a licensing  board  for 
hypnotherapists. 

Leadership  Conference 

The  Louisiana  State  Medical  Society,  along  with  the  LSMS 
Educational  and  Research  Foundation,  enlightened 


Supplement  35  VOL  152  March  2000  J La  State  Med  Soc 


physicians  and  leaders  in  healthcare  on  current  issues 
affecting  medicine  at  its  1999  Leadership  Conference. 
Held  at  the  Baton  Rouge  Hilton,  January  29-30,  1999  the 
conference  offered  more  than  60  participants  and  guests 
information  and  skills  to  assist  them  in  interacting  more 
effectively  with  the  media  and  government,  as  well  as 
becoming  better  advocates  for  the  concerns  of  their 
patients. 

Highlights  of  the  conference  included  a panel 
discussion  on  the  state's  Medicaid  program  which 
featured  experts  on  funding  and  fraud  and  abuse  issues 
from  state  and  federal  agencies.  Members  of  the  local 
media  participated  in  a panel  discussion  offering 
information  for  giving  effective  interviews  and 
presentations  for  newspapers,  television  and  radio 
stations.  That  was  followed  by  an  intensive  training 
session  on  legislative  advocacy  led  by  Joe  Gagen  of 
Legislative  Education  for  Associations  of  Austin,  Texas. 
Mr.  Gagen  led  the  presentation  that  included  ideas  for 
improving  overall  advocacy  in  addition  to  specific  tips 
and  role-playing  opportunities  for  dealing  with 
lawmakers  on  a one-to-one  basis.  He  was  joined  by  former 
state  representative  and  chair  of  the  Louisiana  House  of 
Representatives'  Committee  on  Health  and  Welfare, 
Alphonse  Jackson,  who  presided  over  some  very 
informative  and  entertaining  role-playing  with  several 
conference  attendees. 

Attorney  General  Richard  Ieyoub  was  the 
conference's  luncheon  speaker  on  Saturday  and  provided 
updates  and  information  on  a number  of  timely  issues 
including  the  tobacco  settlement,  managed  care  changes 
in  our  state,  and  the  defense  of  the  Medical  Malpractice 
Act. 

Washington,  DC  Congressional  Delegation  Visit 

An  11-member  group  composed  of  officers  of  the 
Louisiana  State  Medical  Society  and  parish  medical 
society  leaders  visited  our  nation's  capital  the  first  week 
of  March  1999  where  they  met  with  members  of 
Louisiana's  Congressional  Delegation.  The  annual  trip 
was  a great  success  and  during  the  course  of  two  days, 
the  group  was  able  to  meet  with  Sen.  John  Breaux,  Sen. 
Mary  Landrieu,  Rep.  John  Cooksey,  Rep.  Jim  McCrery, 
and  Rep.  William  Jefferson.  They  also  met  with  the  health 
legislative  assistants  of  Rep.  Richard  Baker,  Rep.  Billy 
Tauzin,  and  Rep.  Chris  John.  The  LSMS  delegation 
focused  on  discussing  three  main  topics  of  concern; 
patients'  rights,  fraud  and  abuse,  and  Medicare  reform. 

Concerning  patients'  rights,  the  delegation  stressed 
to  the  lawmakers  that  the  treating  physician  should  retain 
the  right  to  determine  the  medical  necessity  of  medical 
care.  Fair,  medically  based  grievance  and  external  appeals 
were  discussed , as  was  health  plan  accountability  to  make 
health  plans  liable  for  negligent  medical  decision-making 
regarding  denial  of  medical  services. 


The  LSMS  delegation  expressed  deep  concern  over 
the  HCFA  and  AARP  initiative,  and  its  methods  of 
reporting  discrepancies,  which  encouraged  Medicare 
patients  to  report  suspected  Medicare  waste,  fraud  or 
abuse.  The  delegation  also  expressed  their  concerns  that 
HCFA  should  not  encourage  carriers  to  pressure 
physicians  to  waive  their  rights  to  appeal  during  post- 
payment audits,  and  that  physicians  should  have  an 
administrative  right  of  action  against  carriers  who  make 
errors  that  significantly  harm  physicians,  and/or  their 
practices. 


LSMS  Delegation  meets  with  Sen.  John  Breaux  (D)  during  the 
annual  Wahington,  DC  trip,  (l-r)  Keith  DeSonier,  MD,  Chair, 
Committee  on  Federal  Legislation;  David  Treen,  MD,  Jefferson 
Parish;  Floyd  Buras,  MD,  Orleans  Parish;  Bill  Cassidy,  MD, 

EBR  Parish;  Sen.  Breaux;  Leo  Lowentritt,  MD,  LSMS  President; 
Richard  Paddock,  MD,  Jefferson  Parish;  William  T.  Hall,  Chair, 
Board  of  Councilors;  Clint  Lewis,  MD,  President-elect. 

Medicare  reform  talks  concentrated  on  several  major 
points:  1)  finding  a better  way  than  raising  taxes  to  finance 
healthcare  for  older  Americans  2)  structure  Medicare  on 
a system  modeled  after  the  Federal  Employees  Health 
Benefit  Program  3)  reforming  the  Medigap  program  to 
make  it  more  efficient 

LSMS-Sponsored  Actuarial  Review  of  the  Patients’ 
Compensation  Fund 

In  the  spring  of  1999,  the  LSMS  issued  a special  bulletin 
to  the  entire  membership  regarding  the  Society's  concerns 
regarding  a substantial  rate  increase  request  to  the 
Insurance  Rating  Commission  by  the  Patients' 
Compensation  Fund.  On  March  18,  1999  during  the 
meeting  of  the  IRC,  the  LSMS  expressed  great  concern  in 
its  testimony  about  the  impact  of  the  recommended 
physician  rate  increases.  Coupled  with  the  residual 
impact  on  the  rates  charged  by  underlying  carriers,  the 
increase  for  1999  plus  that  of  a proposed  increase  for  the  | 
succeeding  three  years  could  double  some  premiums  paid 
by  physicians. 

At  its  April  7,  1999  meeting,  the  Board  of  Governors 


Supplement  36  VOL  152  March  2000  J La  State  Med  Soc 


approved  a recommendation  from  the  Insurance 
Committee  for  the  LSMS  to  conduct  its  own  actuarial 
study  of  the  status  of  the  fund.  The  LSMS  contracted 
with  the  actuarial  firm  of  Bickerstaff  and  Whatley. 

During  the  summer  and  early  fall,  the  rate  increase 
request  was  postponed  on  several  occasions.  However, 
prior  to  the  completion  of  the  independent  study,  in 
November  1999  the  Insurance  Rating  Commission 
approved  a rate  increase  to  become  effective  on  January 
1,  2000.  David  Bickerstaff  of  Bickerstaff  and  Whatley 
presented  his  findings  to  the  Board  of  Governors  via 
teleconference  at  its  December  15,  1999  meeting. 

Resident  Physician  Membership 

The  LSMS  continued  to  see  growth  in  resident  section 
membership  during  this  year  with  the  announcement  of 
a membership  agreement  with  the  Alton  Oschner  Medical 
Foundation.  Last  year  saw  the  establishment  of  the  first 
in  the  country  housestaff  agreement  for  membership  and 
organized  medicine  at  the  national,  state,  and  component 
society  levels.  The  agreement  with  Tulane  University 
School  of  Medicine  brought  in  483  new  resident  members. 
The  Ochsner  agreement,  modeled  after  the  Tulane 
agreement,  brought  in  an  additional  200  resident 
physician  members.  These  two  agreements  represent  a 
significant  step  in  the  involvement  of  young  physicians 
in  organized  medicine.  Through  the  efforts  of  the 
housestaff  associations  and  organized  medicine  to  provide 
additional  programs  and  activities  for  the  residents,  they 
will  be  more  enlightened  and  prepared  to  deal  with  the 
issues  and  business  responsibilities  as  they  begin  their 
professional  careers. 

Gag  Clause  Challenged 

Gag  clauses  have  long  been  used  by  managed  care 
organizations  to  hinder  physicians  from  effectively 
communicating  important  information  to  their  patients 
so  that  they  could  make  informed  decisions.  Gag  clauses 
have  been  banned  at  both  the  state  and  national  levels, 
but  continue  to  appear  through  crafty  contract  language. 
One  such  situation  was  challenged  by  the  LSMS  in  the 
spring  of  this  year.  The  LSMS  filed  an  official  complaint 
with  the  Louisiana  Department  of  Insurance  regarding 
gag  clauses  contained  in  the  contract  of  a PPO  network 
operating  in  Louisiana.  The  LSMS  responded  to  member 
concerns  about  the  language  in  filing  the  complaint.  As  a 
result  of  the  LSMS  intervention  and  numerous  conferences 
with  DOI  officials,  a letter  was  issued  by  DOI  to  cease 
and  desist  inclusion  of  language  containing  the  gag 
clauses  and  to  remove  the  language  from  all  existing 
contracts.  There  were  a number  of  other  incidents 
throughout  the  course  of  the  year  when  the  LSMS 
Department  of  Legal  Affairs  provided  assistance  to 
members  regarding  MCO  contract  problems  as  well  as 


other  issues  involving  managed  care  relations. 

Dr.  Palmisano  Re-elected  to  AMA  Board 

At  the  Annual  Meeting  of  the  American  Medical 
Association  in  June,  Dr.  Donald  Palmisano  was  re-elected 
to  the  AMA  Board  of  Trustees.  Dr.  Palmisano  received 
the  largest  numbers  of  votes  of  any  candidate  for  the 
Board  of  Trustees.  In  addition,  at  the  conclusion  of  the 
Annual  Meeting,  at  the  organizational  meeting  of  the 
Board  of  Trustees,  he  was  elected  to  the  Executive 
Committee  of  the  Board.  Dr.  Palmisano  was  first  elected 
to  the  Board  in  June  of  1996.  He  has  become  an  articulate 
spokesperson  for  the  AMA  on  many  key  issues  including 
patient  confidentiality,  fraud  and  abuse,  and  professional 
liability.  Dr.  Palmisano  is  also  a founding  member  of  the 
Board  of  Directors  of  the  National  Patient  Safety 
Foundation. 

Patient’s  Choice 

In  August  of  this  year,  the  Board  of  Directors  of  MD 
Healthshares  announced  that  Patient's  Choice,  the  HMO 
subsidiary  of  MD  Healthshares  Corporation,  would  begin 
a winding  down  of  its  operation  under  the  direction  of 
the  Louisiana  Department  of  Insurance.  The  decision  by 
the  Board  of  Directors  was  made  because  the  financial 
reserves  were  not  able  to  reach  break-even  projections. 
The  Department  of  Insurance  issued  its  own  press  release 
concerning  its  actions  and  eventual  supervision  of  the 
operation  of  the  windup  of  the  business  affairs  of  Patient's 
Choice.  In  addition,  the  Department  of  Insurance  notified 
Patient's  Choice  providers  and  enrollees  of  the  process 
in  which  the  affairs  of  Patient's  Choice  would  be  handled. 

Membership 

The  LSMS  has  long  been  a vibrant  and  steadfast 
association  representing  the  interests  and  concerns  of 
physicians  and  the  patients  they  serve.  Louisiana 
physicians  have  long  recognized  the  value  of  a strong 
unified  voice  to  represent  medicine  in  all  areas  of  the 
public  and  private  sectors.  However,  in  recent  years, 
membership  in  the  LSMS  and  its  component  societies  has 
begun  to  stagnate.  By  the  close  of  this  decade  we  had 
experienced  a decline  in  membership  which  began  in 
1996.  The  LSMS  Board  of  Governors  and  Membership 
Committee  as  well  as  the  leadership  of  our  component 
societies  have  increased  efforts  over  the  past  three  years 
to  address  membership.  Although  we  have  seen  a slight 
increase  in  the  number  of  physicians  joining  the  LSMS,  it 
has  not  kept  pace  with  retirements,  transfers  out  of  state, 
and  non-renewals.  Even  more  energy  will  be  focused  on 
membership  activities  in  the  future  and  a vital  part  of 
our  success  will  be  physicians  talking  to  other  physicians 
about  membership  in  the  LSMS. 

Our  members  are  our  most  effective  recruiters  when 


Supplement  37  VOL  152  March  2000  J La  State  Med  Soc 


they  relate  the  positive  results  of  having  a strong 
association  speaking  for  physicians  and  assisting  them 
to  deal  with  the  challenges  that  they  face  in  their  practices. 
The  process  of  rejuvenating  and  building  an  even  stronger 
LSMS  begins  with  each  member  bringing  just  one 
colleague  on  board.  It  is  a simple  yet  personal  way  to 
pass  the  message  on  to  someone  who  is  just  as  concerned 
as  you  are  and  wants  to  do  something  about  it.  I am 
confident  that  our  membership  will  respond  with  the 
sense  of  professionalism  that  has  always  set  the  practice 
of  medicine  apart.  Medicine  is  THE  most  respected 
profession  because  of  its  commitment  to  high  principles 
and  ethics  which  manifests  itself  through  involvement  and 
leadership.  That  leadership  is  carried  out  for  the  good  of 
individuals  and  society  by  organizations  founded  and 
voluntarily  supported  by  physicians.  That  is  why 
physicians  in  Louisiana  since  1878  have  been  a part  of 
the  Louisiana  State  Medical  Society  and  sent  the  message 
down  through  the  decades  that  they  will  lead  the  way  in 
health  care  in  our  state.  The  citizens  of  our  state  have 
come  to  depend  upon  that  and  physicians  now  and  in 
the  future  will  not  waiver  in  providing  that  leadership. 

Y2K 

We  could  not  conclude  a discussion  of  this  year's  activity 
without  at  least  the  mention  of  Y2K.  Yes,  the  LSMS  did 
spend  a great  deal  of  time  and  resources  preparing  in  the 
best  way  possible  to  deal  with  the  dreaded  possible 
consequences  of  the  mysterious  Y2K  bug.  And  the  LSMS, 
like  almost  every  person  and  business  saw  Y2K  arrive 
without  so  much  as  a single  blip  on  our  computer  screen. 
All  of  the  effort  certainly  was  not  without  some  benefit 
as  the  Y2K  scare  provided  the  opportunity  and  motivation 
to  conduct  a thorough  review  of  our  computer  systems. 
As  a result,  there  were  some  changes  and  upgrades  that 
certainly  will  make  us  more  efficient  and  help  provide 
better  service  in  the  future. 

Conclusion 

Depending  upon  how  exact  you  are  in  computing  the 
beginning  and  ending  of  centuries  and  millenia,  the  year 
2000  will  be  starting  or  finishing  a milestone  in  history. 
Almost  all  of  us  agree  that  we  as  individuals  and 
organizations  are  beginning  a new  era  in  our  lives.  It  is 
almost  as  if  the  psychology  of  the  year  2000  says  to  us  we 
are  starting  with  a clean  slate,  a fresh  start.  That  is  true 
with  every  new  year  that  we  celebrate.  By  whatever  way 
we  define  the  meaning  of  the  year  2000,  be  assured  the 
LSMS  will  be  a part  of  the  dynamics  that  affect  and 
respond  to  the  changes  that  continue  to  occur  in  healthcare 
and  be  your  voice,  the  voice  of  Medicine  in  Louisiana. 

Dave  Tarver 
Executive  Vice  President 


DEPARTMENT  OF  ADMINISTRATION 

Administration  is  responsible  for  the  day-to-day 
operations  of  the  LSMS,  the  CME  Accreditation  Program, 
the  Annual  Meeting  of  the  House  of  Delegates,  the  LSMS 
Educational  and  Research  Foundation  and  the 
administrative  support  of  several  committees. 

Much  of  the  staff's  time  is  spent  administering  the 
CME  Accreditation  Program  (CMEAP).  The  CMEAP  is 
recognized  by  the  Accreditation  Council  for  Continuing 
Medical  Education  (ACCME)  to  accredit  organizations  in 
Louisiana  to  designate  AMA  Category  1 and  2 credit  to 
educational  offerings.  The  CMEAP  went  through  the 
recognition  process  from  ACCME  in  July  with 
representatives  from  Virginia  and  Tennessee  surveying 
the  program.  We  received  four  more  years  of  recognition 
with  an  exemplary  recognition  for  our  communication 
process  with  our  providers.  Louisiana's  program 
accredited  one  new  provider  in  1999  and  reaccredited  ten 
providers.  We  have  a total  of  thirty-three  intrastate 
providers  in  Louisiana. 

The  accreditation  system  that  is  used  to  assure  that 
all  accredited  organizations  are  providing  the  same 
quality  CME  is  being  revamped  in  2000.  The  CMEA 
Committee  formed  a subcommittee  to  look  at  the  new 
system  and  make  recommendations  to  the  full  committee 
regarding  the  criteria  to  be  used  and  to  develop  forms  for 
the  new  system.  A new  Reference  Manual  was  also  written 
for  providers  to  assist  them  in  administering  their  local 
CME  program.  The  CME  Accreditation  Committee  is  one 
of  the  hardest  working  committees  of  the  Society  with 
quarterly  meetings  and  site  surveys  as  well  as  reviewing 
all  applications.  With  all  of  the  work  that  took  place  this 
year  the  members  of  this  committee  volunteered  338  hours 
during  1999. 

The  LSMS  and  the  Medical  Association  of  the  State  of 
Alabama  hosted  a meeting  in  New  Orleans  with  staff  from 
eight  state  medical  societies  represented  to  discuss  the 
new  accreditation  system  and  how  different  states  were 
planning  to  implement  it.  This  meeting  was  valuable  in 
that  it  provided  a forum  to  exchange  ideas  about  what  is 
working  in  other  states  to  improve  the  dissemination  of 
quality  CME  for  physicians. 

This  year  CME  Accreditation  Program  held  biannual 
meetings  with  the  intrastate  CME  Coordinators  to  keep 
them  current  on  the  new  system,  new  policies  in  CME 
and  to  discuss  any  topics  that  the  coordinators  may  be 
having  difficulty  with  in  their  organizations.  In  1999,  an 
Essentials  Workshop  was  held  for  accredited 
organizations  with  new  CME  coordinators,  organizations 
in  the  process  of  being  accredited  and  organizations  that 
were  considering  seeking  accreditation  in  1999.  The 
newsletter,  CMEssentials , edited  by  Toni  Smith,  is 
published  quarterly  and  is  sent  to  all  hospitals  and  other 
organizations  interested  in  CME  in  Louisiana.  In  addition, 


Supplement  38  VOL  152  March  2000  J La  State  Med  Soc 


the  CMEAP  maintains  a CME  Calendar  on  the  LSMS  web 
page  and  in  the  Journal  for  any  Louisiana  organizations 
interesting  in  publicizing  their  activities. 

The  staff  also  spoke  at  two  statewide  Medical  Staff 
Coordinators  meetings  held  at  Touro  Hospital  in  New 
Orleans  and  Woman's  Hospital  in  Baton  Rouge  about  the 
functions  of  the  LSMS  and  how  we  can  help  them. 

W.  Gardner  Rhea,  MD,  a member  of  the  CMEA 
Committee  and  Jeanette  Harmon,  Director  of 
Administration  were  both  chosen  by  the  ACCME  to  be 
site  surveyors  for  the  Committee  on  Review  and 
Recognition  that  is  responsible  for  recognizing  state 
medical  societies.  Ms.  Harmon  traveled  to  Eureka  Spring, 
Arkansas  to  evaluate  the  Arkansas  Medical  Association's 
program  in  October.  While  there  she  was  also  a presenter 
at  the  Arkansas  Annual  CME  Sponsors  Forum.  Ms. 
Harmon  also  served  as  a faculty  member  for  a national 
ACCME  Essentials  Workshop  in  Chicago  in  April. 

The  LSMS  jointly-sponsors  an  annual  regional  CME 
symposium  with  the  state  medical  societies  of  Arkansas, 
Alabama  and  Mississippi.  This  year  the  15th  Annual 
Southeast  Regional  CME  Symposium  was  held  in 
September  in  Point  Clear,  Alabama.  Two  members  of  the 
CMEA  Committee  attended  as  well  as  LSMS  staff  and  8 
people  from  accredited  institutions  in  Louisiana. 

Administration  also  staffs  the  Committees  on 
Geriatrics,  Chronic  Diseases  and  Medical  Education. 
These  committees  met  as  needed  in  1999  to  deal  with 
issues  referred  to  them  by  the  Board  of  Governors  or  the 
House  of  Delegates.  The  Geriatrics  and  Chronic  Diseases 
Committees  continue  to  meet  jointly  when  issues  involve 
the  charges  of  both  of  the  committees.  The  Chronic 
Disease  committee  is  launching  a statewide  osteoporosis 
campaign  in  2000.  These  committees  continue  to  be  active 
in  carrying  out  their  purposes  and  charges. 

Administration  also  provided  staff  support  for  the  Ad 
Hoc  Committee  on  Operations  and  Functioning  of  the 
House  of  Delegates.  This  committee  made  several 
recommendations  to  the  House  of  Delegates  in  October. 

The  Educational  and  Research  Foundation  also  falls 
under  the  auspices  of  this  department  with  the  CME 
Program  being  one  of  its  major  responsibilities.  This 
program  was  originally  established  to  "fill  in  the  gaps" 
in  CME  in  Louisiana.  This  year  the  ERF  jointly-sponsored 
CME  activities  with  three  parish  medical  societies  and  a 
state  specialty  society  as  well  as  the  LSMS  Leadership 
Conference  that  was  held  in  January.  The  ERF  also  houses 
the  Philip  H.  Jones,  MD  Scholarship  Program  which 
awards  scholarships  to  outstanding  medical  students  in 
Louisiana. 

Staff  attended  several  conferences  this  year  on  behalf 
of  the  LSMS.  These  included  the  AMA  Leadership 
Confluence,  the  Medical  Society  of  Alabama  Annual 
Meeting,  the  AMA  Meeting  in  June,  the  Alliance  for  CME 
24  th  Annual  Meeting  and  the  ACCME /State  Medical 
Society  Annual  Meeting. 


One  of  the  major  functions  of  this  department  is  the 
planning  and  execution  of  the  LSMS  Annual  Meeting  of 
the  House  of  Delegates.  The  1999  meeting  was  held  at 
the  Baton  Rouge  Radisson  Hotel  and  Conference  Center 
on  October  21-23  with  the  HOD  acting  on  70  resolutions. 
The  Past  Presidents  were  honored  at  a dinner  held  at 
Juban's  Creole  Restaurant  on  October  21.  The  50-year 
Physicians  were  also  honored  at  a reception  on  October 
22  and  recognized  individually  before  dinner. 

The  LSMS  continues  to  improve  the  computer  system 
used  by  the  staff  with  the  web  page  now  being  housed  on 
the  LSMS  server  for  greater  control.  The  staff  worked  with 
Governmental  Affairs  and  Public  Affairs  in  keeping  the 
LSMS  web  site  up-to-date  on  legislative  matters  and  in 
sending  weekly  email  alerts  out  to  the  members  during 
the  legislative  session.  We  also  used  blast  faxes  to  target 
certain  groups  of  physicians  when  it  was  appropriate. 

A staff  retreat  was  held  in  November  to  try  to  unify 
the  staff  and  establish  some  goals  for  2000.  The  retreat 
made  us  aware  of  how  the  different  departments  of  the 
LSMS  fit  together  and  steps  that  need  to  be  implemented 
to  make  us  more  efficient  in  carrying  out  the  business  of 
the  Society.  This  is  something  that  we  will  continually  have 
to  work  on. 

Administration  is  very  fortunate  to  have  Toni  Smith, 
Medical  Education  Coordinator,  and  Bonna  White,  Copy 
Specialist,  on  staff.  Ms.  White  resigned  effective  December 
31  and  will  be  greatly  missed.  However,  Carol  Hollinger 
has  already  been  hired  to  fill  this  position  and  we  are  sure 
that  she  is  going  to  be  an  asset. 

Jeanette  Harmon 
Director  of  Administration 

DEPARTMENT  OF  GOVERNMENTAL  AFFAIRS 

Legislative  Activities 

The  year  began  with  development  and  implementation 
of  the  LSMS  campaign  against  non-physician  prescribing 
which  was  entitled  "Prescription  for  Disaster."  This 
campaign  was  an  effort  to  thwart  legislative  attempts  by 
non-physicians,  especially  psychologists  and  physician 
assistants,  to  gain  prescriptive  authority  through 
legislation  rather  than  educational  endeavors. 

In  the  months  prior  to  the  beginning  of  the  legislative 
session,  the  staff  of  the  Department  of  Governmental 
Affairs  (DGA)  participated  in  many  legislative  dinners 
and  receptions  held  by  component  societies  for  their  area 
legislators.  In  addition,  the  LSMS  hosted  a reception  in 
Baton  Rouge  on  April  13th  for  the  entire  legislature,  which 
was  well  attended  by  both  legislators  and  physicians  from 
around  the  state. 

The  1999  Regular  Session,  which  began  on  March  29th, 
ended  on  Monday,  June  21  at  6:00  p.m.  During  the  85- 
day  session,  the  LSMS  achieved  an  overwhelming 


Supplement  39  VOL  152  March  2000  J La  State  Med  Soc 


;*  "U-'- 


measure  of  success, 
which,  in  great  part, 
was  due  to  the  very 
effective  grassroots 
effort  of  the  mem- 
bership. On  behalf  of 
the  LSMS 

membership,  the 
DGA  extends  special 
thanks  to  all 
physicians,  and 
Alliance  members, 
who  either  came  to 
the  Capitol  to  support 
LSMS  efforts  or 
contacted  legislators 
at  their  district  office  or  at  the  Capitol.  The  legislators 
related  to  us  that  this  was  the  largest  outpouring  of  mail 
and  communication  from  the  LSMS  that  they  had  ever 
seen.  By  the  middle  of  the  session,  most  legislators  were 
well  aware  of  our  issues.  Without  such  grassroots  contact, 
our  success  could  not  have  been  achieved. 

Our  success  in  the  1999  Regular  Legislative  Session 
was  one  of  the  best  on  record.  The  LSMS  passed  81%  of 
its  legislative  priorities.  Most  importantly,  not  a single 
piece  of  legislation,  which  the  LSMS  actively  opposed, 
was  enacted  into  law. 


1999  Regular  Session:  Greatest  Hits 

♦ The  LSMS  blocked  attempts  by  the  psychologists  and 
physician  assistants  to  obtain  prescriptive  authority. 

♦ The  hypnotherapists'  attempt  to  establish  their  own 
licensing  board  was  defeated  in  committee. 

♦ The  LSMS  was  part  of  a healthcare  coalition,  which 
passed  legislation  mandating  health  insurance 
coverage  for  13  of  the  most  severe  mental  illnesses. 
This  was  a major  victory  that  had  been  sought  for 
many  years  and  was  vehemently  opposed  by  business 
and  insurance  interests. 

♦ The  LSMS  defeated  numerous  attempts  to  increase 
the  limitation  of  liability  for  medical  malpractice  from 
$500,000  to  as  much  as  $2.5  million,  or  to  entirely 
remove  the  cap. 

♦ The  LSMS  defeated  an  attempt  to  place  a hospital- 
based  physician,  nominated  by  the  Louisiana  Hospital 
Association,  on  the  Louisiana  State  Board  of  Medical 
Examiners. 

♦ The  fiscal  year  1999-2000  Medicaid  Budget  was 
maintained,  in  the  face  of  proposed  cuts,  at  a funding 
level  of  $193  million  for  private  physicians'  services. 

♦ As  part  of  another  healthcare  coalition,  the  LSMS 
successfully  blocked  legislation  that  was  a medically 
unwise  attempt  to  change  the  childhood 
immunization  schedule  for  mumps,  measles  and 
rubella. 


♦ The  LSMS  passed  legislation  that  provides  a limitation 
of  liability  for  healthcare  providers  rendering 
gratuitous  services  in  their  private  offices  through 
referral  from  a free  clinic  or  a virtual  clinic. 

♦ An  LSMS  backed  bill  establishing  standards  for  timely 
payment  of  health  insurance  and  enrollee  claims 
passed  the  legislature  and  was  enacted  into  law. 

♦ An  LSMS-backed-bill  providing  for  licensure, 
standards,  and  liability  of  organizations  making 
medical  necessity  determinations  passed  the 
legislature  and  was  enacted  into  law.  The  law 
provides  for  internal  and  external  appeals  procedures 
and  standards  for  managed  care  entities  that  engage 
in  medical  necessity  review  determinations.  The  law 
also  includes  a patient's  right  to  sue  a managed  care 
entity  for  negligence  or  gross  negligence  related  to 
the  rendering  of  medical  necessity  decisions. 

Unfortunately,  we  were  unsuccessful  in  passing 
legislation  to  help  protect  the  actuarial  soundness  of  the 
Patient's  Compensation  Fund  (PCF).  This  legislation 
would  have  provided  for  a reimbursement  schedule  for 
the  payment  of  future  medical  care  directly  to  providers, 
a uniform  and  expanded  definition  of  "malpractice"  and 
allowed  the  PCF  to  receive  credit  for  other  insurance  the 
injured  patient  may  have.  These  changes  could  have 
saved  the  PCF  more  than  $3.17  million  a year. 

These  are  only  a few  of  the  approximately  750  bills 
that  affected  medicine  in  some  way.  A full  report  of 
legislation  impacting  medicine  can  be  found  in  the  1999 
Legislative  Summary  that  was  mailed  to  all  LSMS 
members  in  August,  1999. 

Post  Legislative  Session  Survey 

The  Department  of  Governmental  Affairs  included  a 
"1999  Post  Legislative  Session  Survey"  in  the  1999  Legis- 
lative Summary.  The  Council  on  Legislation  and  the  De- 
partment of  Governmental  Affairs  were  anxious  to  receive 
and  review  the  results  from  the  survey.  The  information 
gleaned  from  the  survey  would  have  better  enabled  the 
LSMS  to  represent  and  respond  to  medicine's  concerns 
in  the  legislative  process.  Unfortunately,  only  55  physi- 
cians out  of  approximately  6,800  completed  and  returned 
the  one-page  survey.  This  represents  a response  of  less 
than  1%  of  the  LSMS  membership. 

Additional  Lobbyists 

The  LSMS  added  to  its  lobbying  efforts  this  year  by  hiring 
contract  lobbyists,  Harris,  DeVille  and  Associates  and 
former  state  representative  Alphonse  Jackson.  They  were 
extremely  instrumental  in  our  success  during  the  session. 
In  addition.  The  Louisiana  Psychiatric  Medical 
Association's  (LPMA)  contract  lobbyist,  Vera  Olds, 
worked  diligently  with  the  LSMS  to  defeat  the  psy- 
chology prescribing  issue  and  pass  the  mandate  for  health 


Supplement  40  VOL  152  March  2000  J La  State  Med  Soc 


insurance  coverage  of  13  diagnoses  of  severe  mental 
illness.  The  coordinated  efforts  of  the  DGA  staff,  the  LSMS 
contract  lobbyists  and  Ms.  Olds  were  critical  to  our  success 
on  these  two  priority  issues. 

Enhanced  Communication  with  Membership 

To  prepare  for  the  session,  the  LSMS  developed  better 
ways  to  communicate  with  its  members  through  e-mail, 
blast  fax  and  the  LSMS  web  site.  We  now  have  the 
capability  to  e-mail  more  than  fifteen  hundred  members. 
We  implemented  a system  for  blast  faxes,  which  was  used 
extensively  during  the  legislative  session.  The  DGA 
developed  weekly  legislative  updates,  calls  to  action,  and 
talking  points  on  key  issues  and  posted  them  on  our  web 
page.  The  new  LSMS  Grassroots  Action  Center,  also 
found  on  the  web  site,  was  used  effectively  by  LSMS 
members  to  identify  and  communicate,  via  e-mail,  with 
their  legislators. 

Fall  Elections 

In  the  fall  of  1999,  elections  were  held  for  all  seats  in  the 
legislature  and  for  all  statewide  elected  officials.  As  a re- 
sult, immediately  following  the  close  of  the  regular  ses- 
sion, attention  shifted  to  L AMPAC  and  its  role  in  this  pro- 
cess. The  staff  of  the  DGA  met  with  incumbent  legisla- 
tors and  challengers  and  made  recommendations  to  the 
L AMPAC  board.  Once  the  contributions  were  approved, 
the  DGA  staff,  along  with  LAMPAC  board  members,  be- 
gan delivering  the  contributions  to  the  candidates,  as  well 
as  to  legislators  who  were  unopposed.  The  contributions 
were  well  received  and  will  help  build  strong  relation- 
ships with  members  of  the  legislature.  This,  in  turn,  will 
give  us  a greater  ability  to  communicate  with  legislators 
on  issues  that  affect  medicine. 

State  Regulatory  Activities 

Although  the  primary  focus  of  the  Department  of  Gov- 
ernmental Affairs  during  1999  was  the  Regular  Session 
of  the  Louisiana  Legislature  and  the  fall  elections, 
throughout  the  year,  the  DGA  was  involved  in  a variety 
of  other  governmental  activities  which  impact  the  prac- 
tice of  medicine. 

During  the  year,  the  DGA  regularly  attended  meet- 
ings of  the  Louisiana  Health  Care  Commission,  Joint  Leg- 
islative Committee  on  the  Budget,  Insurance  Rating  Com- 
mission, Patient's  Compensation  Fund  Oversight  Board, 
Disparity  Commission,  and  the  Minority  Health  Affairs 
Commission. 

As  in  the  past,  the  DGA  was  involved  in  administra- 
tive rulemaking  by  various  state  agencies.  Among  the 
rules  for  which  the  DGA  provided  official  comments  were 
the  Medicaid  Program's  Surveillance  and  Utilization  Re- 
view System  (SURS)  rule  relating  to  fraud  and  abuse  and 
was  able  to  elicit  significant  changes.  The  DGA  also  moni- 
tored the  final  rules  for  the  implementation  of  the  APRN 


limited  prescriptive  authority  promulgated  jointly  by  the 
Louisiana  State  Board  of  Medical  Examiners  and  the  Loui- 
siana State  Board  of  Nursing.  Finally,  the  DGA  provided 
written  comments  for  rules  to  implement  legislative  revi- 
sions to  the  physician  assistants  practice  act. 

The  DGA  continued  to  foster  an  excellent  working 
relationship  with  Department  of  Insurance  Commissioner 
Jim  Brown  and  Deputy  Commissioner,  Richard  O'Shee, 
Director  of  the  Department's  Office  of  Health  Insurance. 
The  LSMS  worked  closely  with  the  Department  of 
Insurance  (DOI)  to  pass  HB  2083  and  HB  2052.  HB  2083 
provided  requirements  for  entities  making  medical 
necessary  decisions  (Medical  Necessity  Review 
Organizations,  MNROs),  including  the  right  to  sue  such 
entities  for  negligent  acts.  HB  2052  established  procedures 
and  time  frames  for  the  prompt  payment  of  health  services 
by  both  HMOs  and  health  insurance  plans.  In  2000,  the 
DGA,  in  conjunction  with  DOI,  is  participating  in  the 
drafting  of  the  rules  and  regulations  to  implement  both 
of  these  pieces  of  legislation. 

The  LSMS  staff  and  its  officers  instituted  quarterly 
meetings  with  Secretary  David  Hood  of  the  Department 
of  Health  and  Hospitals  (DHH)  to  maintain  a good 
working  relationship  with  DHH. 

Congressional  Activities 

The  LSMS  and  the  Department  of  Governmental  Affairs 
monitored  federal  legislation  such  as  a version  of  the 
Patient's  Bill  of  Rights  supported  by  the  AMA  that  passed 
the  House  of  Representatives  in  the  fall  of  1999.  LSMS 
representatives  met  with  all  of  the  members  of  the 
Louisiana  congressional  delegation,  or  their  aides,  on  our 
Annual  Washington  Congressional  visit.  Those  attending 
included  Dr.  Clint  Lewis,  Dr.  William  Hall,  Dr.  Keith 
DeSonier,  Dr.  Bill  Cassidy,  Dr.  Floyd  Buras,  Dr.  David 
Treen,  Dr.  Richard  Paddock.  Key  issues  discussed  were 
fraud  and  abuse,  Medicare  reform,  and  patients'  rights. 
In  addition,  Dr.  Lewis  and  Dr.  Lowentritt,  accompanied 
by  DGA  staff,  attended  the  Mardi  Gras  in  Washington 
where  they  made  and  renewed  many  important  contacts 
among  our  congressional  delegation  and  their  staffs. 

Committees 

The  DGA  provided  staff  and  support  for  the  following 
committees  of  the  LSMS:  the  Council  on  Legislation,  the 
Committee  on  Federal  Legislation,  the  Specialty  Society 
Committee,  the  Liaison  with  Health  Professionals 
Committee,  the  Disaster  and  Emergency  Services 
Committee,  and  the  Sports  Medicine  Committee. 

The  mission  of  the  Department  of  Governmental 
Affairs  is  to  provide  strong,  effective  advocacy  for  the 
Louisiana  State  Medical  Society  in  promoting  the  best 
interests  of  the  patients  of  Louisiana  and  protecting  the 
autonomy  and  high  quality  of  medical  practice.  As  such, 
the  DGA  stands  ready,  with  the  help  of  the  LSMS 


Supplement  41  VOL  152  March  2000  J La  State  Med  Soc 


membership,  to  meet  whatever  challenges  the  next  year 
may  bring. 

Sharon  Knight,  JD 
Director  of  Governmental  Affairs 

DEPARTMENT  OF  LEGAL  AFFAIRS 

The  mission  of  the  Department  of  Legal  Affairs  is  to 
provide  legal  information,  guidance  and  assistance  to 
LSMS  member  physicians,  the  Board  of  Governors  (BOG), 
LSMS  Committees,  Component  Medical  Societies,  the 
Journal  of  the  Louisiana  State  Medical  Society,  the 
Physicians'  Health  Foundation  of  Louisiana,  the  LSMS 
Educational  and  Research  Foundation  and  the  LSMS  staff. 
The  responsibilities  of  the  department  include  advising 
the  BOG  on  all  corporate  legal  matters,  drafting  various 
documents  in  support  of  the  objectives  or  positions  of  the 
LSMS,  representation  of  and  advocacy  for  the  LSMS  in  a 
variety  of  settings,  supervision  of  the  Physicians'  Health 
Foundation  of  Louisiana  (PHFL),  and  serving  as  staff 
liaison  to  the  Louisiana  State  Board  of  Medical  Examiners 
(LSBME)  and  the  Louisiana  Medical  Disclosure  Panel.  The 
Department  of  Legal  Affairs  provided  staff  support  to 
several  LSMS  committees  during  1999  including  the 
Medical /Legal  Interprofessional  Committee,  Committee 
on  Evolving  Trends  in  Medicine,  Physicians'  Health 
Committee,  and  the  Ad  Hoc  Managed  Care  Liaison 
Committee.  The  department  also  assists  the  LSMS 
American  Medical  Association  (AMA)  delegation. 

One  of  the  most  important  functions  of  the 
department  is  to  respond  to  requests  for  legal  information 
and  guidance  from  our  members.  A vast  majority  of  the 
calls  received  by  the  department  this  year  focused  on  the 
numerous  problems  caused  by  managed  care.  Members 
sought  assistance  with  issues  such  as:  contract  review, 
interpretation,  and  negotiation;  utilization  review;  pre- 
certification problems;  and,  timely  payment.  The 
department  cannot  represent  individual  physicians,  but 
can  provide  our  members  with  suggestions  on  how  to 
deal  with  these  issues. 

During  the  last  year,  the  department  also  responded 
to  questions  from  our  members  on  the  following  topics: 
how  to  respond  to  a subpoena;  depositions,  medical 
records  and  confidentiality  issues;  hospital  medical  staff 
issues;  Medicare  and  Medicaid  problems:  the  LSMBE's 
Pain  Rules;  informed  consent  issues;  risk  management; 
the  medical  review  panel  process;  closing  a medical 
practice;  the  Americans  with  Disabilities  Act  (ADA)  and 
its  effect  on  physicians;  Occupational  Safety  and  Health 
Administration  (OSHA)  standards;  termination  of  the 
physician-patient  relationship;  worker's  compensation 
issues;  living  wills  and  advance  directives;  federal  and 
state  fraud  and  abuse  issues;  and  various  other  medical 
legal  issues. 


The  Department  of  Legal  Affairs  serves  as  the  staff 
liaison  to  the  Louisiana  Medical  Disclosure  Panel,  which 
is  a statutorily  created  panel  of  physicians  and  attorneys. 
The  panel  develops  the  list  of  risks  that  physicians  should 
inform  their  patients  about  prior  to  medical  treatment  or 
surgery.  The  panel  also  developed  an  informed  consent 
form  that,  when  used  in  conjunction  with  the  appropriate 
list  of  risks,  provides  the  physician  with  the  best  protection 
available  against  medical  malpractice  suits  based  upon 
the  failure  to  provide  the  patient  with  sufficient 
information  for  them  to  give  informed  consent  to  the 
treatment  or  surgery.  The  department  regularly  assists 
members  with  informed  consent  questions. 

The  department  provided  staff  support  and  legal 
guidance  to  the  Ad  Hoc  Managed  Care  Liaison  Committee 
(MCLC).  The  department  worked  very  closely  with  this 
Committee  in  looking  for  ways  to  assist  our  members  in 
the  managed  care  environment.  The  MCLC  was 
responsible  for  planning  and  hosting  the  LSMS  Managed 
Care  Summit,  which  was  held  on  September  23, 1998.  The 
MCLC  believed  that  the  Summit  would  be  a first  step 
towards  solving  some  of  the  problems  associated  with 
managed  care.  In  1999,  the  MCLC  and  the  department 
continued  to  pursue  resolution  of  the  following  issues, 
which  were  discussed  at  the  Summit:  1)  external  and 
internal  grievance  procedures;  2)  disclosure  of  payment 
schedules  and  a health  plan  comparison  document;  3) 
definition  of  covered  services  and  medical  necessity;  4) 
termination  without  cause  and  gag  clauses;  5) 
confidentiality  of  medical  records;  and,  6)  a standardized 
credentialing  form. 

The  Louisiana  Health  Care  Alliance  (LHCA)  formed 
several  Subcommittees  following  the  Summit  to  continue 
working  on  solutions  to  several  of  the  issues  that  were 
discussed  at  the  Summit.  The  Subcommittees  included 
Standardized  Credentialing  Form  Subcommittee;  Patient 
Education  Subcommittee;  Patient  Appeal  and  Grievance 
Subcommittee;  and  the  Patient  Confidentiality 
Subcommittee.  The  General  Counsel  participated  in  the 
work  of  these  Subcommittees  on  behalf  of  the  MCLC  and 
the  LSMS.  The  most  exciting  thing  to  come  out  of  the 
Summit  and  then  the  LHCA  Standardized  Credentialing 
Subcommittee  was  the  development  of  a standardized 
credentialing  form.  The  Subcommittee  developed  the 
form  and  it  is  our  understanding  that  the  Louisiana 
Department  of  Insurance  plans  to  publish  the  form  as  a 
regulation  and  that  all  HMO's  operating  in  the  state  will 
be  required  to  use  the  form.  All  of  the  other  LHCA 
Subcommittees  are  continuing  to  work  on  the  problems 
discussed  at  the  Summit.  The  department  will  continue 
to  work  closely  with  the  MCLC  as  we  all  strive  to  solve 
the  problems  caused  by  the  advent  of  managed  care. 

The  department  reviews  and  advises  the  BOG  on  all 
requests  for  Amicus  Curiae  briefs.  The  LSMS  submits 
Amicus  Curiae  briefs  in  cases  that  could  adversely  affect 


Supplement  42  VOL  152  March  2000  J La  State  Med  Soc 


the  practice  of  medicine  in  Louisiana  and  in  cases  that 
threaten  the  protections  of  the  Medical  Malpractice  Act. 
The  L5MS  is  committed  to  the  continued  preservation  of 
the  protections  established  by  the  Act  and  stands  ready 
to  consider  Amicus  Curiae  briefs  requests  in  cases  that 
threaten  it.  We  have  been  very  fortunate  to  have  worked 
'with  the  Legal  Department  at  LAMNGCO  on  several  of 
the  Amicus  Curiae  briefs  we  filed  this  year. 

In  1999,  the  department  assisted  numerous  physicians 
with  managed  care  contracting  problems.  In  January,  the 
department  received  several  calls  from  member 
physicians  regarding  their  recent  terminations  as 
providers  with  a local  PPO  Network.  The  termination 
letter  quoted  a non-solicitation  clause  in  the  physician's 
contract,  which  attempted  to  prohibit  the  contracted 
phvsicians  from  communicating  with  their  patients 
regarding  their  healthcare  and/or  alternative  coverage 
arrangements.  The  department  reviewed  the  provision 
and  immediately  sent  an  official  written  complaint  to  the 
Department  of  Insurance  (DOI)  asking  them  to  review 
the  provision,  which  appeared  to  be  a "gag  clause"  in 
violation  of  Louisiana  law.  The  DOI  determined  that  this 
clause  was  indeed  a "gag  clause"  and  directed  the  PPO 
Network  to  remove  the  provision  from  all  of  their 
contracts.  For  more  information  on  "gag  clauses,"  see 
the  Mav/June  1999  edition  of  Capsules. 

The  department  worked  very  hard  in  early  1999  to 
help  our  members  with  problems  caused  by  fee  schedule 
changes  proposed  by  the  State  Employee  Group  Benefits 
Program  (SEGBP).  The  problems  began  when  the  SEGBP 
issued  a Notification  of  Fee  Schedule  Change  and  a 
Revised  Fee  Schedule  to  all  of  its  participating  physicians 
on  December  29,  1998.  Their  cover  letter  indicated  that 
the  enclosed  contract  amendment  had  to  be  signed  and 
returned  to  the  SEGBP  by  February  1,  1999.  Most 
physicians  did  not  receive  the  letter  until  Januarv  6, 1999. 
Many  physicians  questioned  the  accuracy  of  some  of  the 
information  contained  in  the  Notification.  The  original 
Notification  included  a contract  amendment  for 
physicians  to  sign  along  with  the  new  Fee  Schedule.  The 
complaints  centered  on  the  inconsistencies  between  the 
Fee  Schedule  information  in  the  cover  letter  and  the 
contract  amendment  and,  in  some  instances,  the  attached 
Fee  Schedule.  Responding  to  the  many  complaints,  the 
department  immediately  contacted  the  SEGBP  to  discuss 
the  concerns  of  our  members.  The  LSMS  sent  a letter  to 
the  SEGBP  carefully  describing  the  problems  and  making 
several  requests  for  changes.  The  LSMS  received  a letter 
on  January  22,  1999  from  the  SEGBP  stating  that,  in 
response  to  our  letter,  the  SEGBP  would  send  out  a new 
Notification  to  physicians.  The  department  stands  ready 
to  assist  members  with  problems  like  this  one  and 
welcomes  complaints  from  our  members. 

As  discussed  above,  the  department  regularly  assists 


member  physicians  with  contract  problems.  In  order  to 
participate  in  the  Medicaid  program,  Louisiana  phvsicians 
were  required  to  purchase  or  lease  equipment  that  could 
read  Medicaid  swipe  cards.  In  Februarv,  a member 
physician  complained  to  the  department  about  an 
indemnity  provision  in  the  agreement  to  purchase  the 
swipe  card  reader  equipment.  The  department  reviewed 
the  provisions  and  discovered  that  the  contract  contained 
a very  expansive  mdemnity  and  hold  harmless  clause  that 
put  the  physician  in  the  position  of  indemniWing  the 
Louisiana  Department  of  Health  and  Hospitals  (DHH), 
Unisys  and  the  companies  providing  the  equipment  for 
any  negligence  associated  with  the  information 
transmitted  through  the  swipe  card  system. 

The  department  immediately  contacted  DHH  and 
argued  that  physicians  had  no  control  over  the  verification 
process  and  should  not  be  forced  to  indemnifv  anvone 
for  a process  they  do  not  control.  The  department 
requested  that  the  mdemnity  and  hold  harmless  clauses 
provision  be  removed  from  these  contracts.  Two  months 
later,  the  Director  of  Louisiana  Medicaid  agreed  with  the 
department  that  these  provisions  were  inappropriate  and 
should  be  removed  from  all  of  the  contracts  for  the  lease 
or  purchase  of  the  swipe  card  reader  equipment.  The 
department  is  available  to  assist  member  physicians  with 
problems  of  this  nature. 

The  Department  of  Legal  Affairs  looks  forward  to  the 
challenges  the  year  2000  will  bring.  In  2000,  the 
department  will  develop  and  publish  a fraud  and  abuse 
manual  that  will  be  available  to  all  LSMS  members.  It  is 
our  hope  that  this  manual  will  educate  our  members  on 
the  myriad  of  fraud  and  abuse  and  compliance  issues  and 
will  provide  them  with  the  tools  to  protect  themselves  if 
the  government  comes  calling. 

We  will  continue  our  advocacy  efforts  with  the  courts 
and  regulatorv  agencies  on  behalf  of  our  members  in  2000, 
and  look  forward  to  assisting  as  many  members  as 
possible  in  2000.  We  encourage  our  member  physicians 
to  contact  the  legal  department  if  they  need  assistance 
with  contract  issues  or  any  of  the  other  medical  legal 
issues. 

Amy  TV7.  Phillips , JD 
Director  of  Legal  Affairs  and  General  Counsel 

DEPARTMENT  OF  MEMBERSHIP 
AND  FINANCE 

The  Department  of  Membership  and  Finance  continued 
to  adapt  to  change  in  1999.  The  department  is  tasked 
with  the  responsibility  for  recruitment  and  retention  of 
members  and  the  provision  of  membership  sendees,  along 
with  management  of  all  financial  functions  of  the  Society 


Supplement  43  VOL  152  March  2000  J La  State  Med  Soc 


such  as  investments  and  financial  reporting.  The 
department  is  responsible  for  all  staff  work  for  the 
Membership,  Budget  and  Finance,  Insurance,  and  Young 
Physicians'  committees,  in  addition  to  its  regular  duties. 

With  assistance  from  the  Orleans  and  Jefferson  Parish 
Medical  Societies  and  the  AMA,  an  agreement  was 
reached  to  bring  approximately  200  Ochsner  residents  into 
membership  in  the  LSMS.  This  agreement,  similar  to  the 
one  with  the  Tulane  Housestaff  Association,  will  give  the 
LSMS  the  opportunity  to  work  on  behalf  of  residents  and 
show  them  the  benefits  of  membership  in  organized 
medicine.  The  LSMS  and  components  will  provide 
specific  programs  to  residents  tailored  to  their  educational 
needs,  in  addition  to  their  normal  benefits. 

The  Membership  Committee  held  three  meetings 
during  1999,  in  an  attempt  to  implement  programs  to 
enhance  recruitment  and  retention  of  active  members  of 
the  LSMS.  In  late  1998,  the  BOG  asked  the  committee  to 
study  the  possibility  of  adding  a new  category  of 
membership  for  physicians.  This  category  was  designed 
to  appeal  to  physicians  who  work  as  Medical  Directors 
or  Administrators  for  insurance  companies  and  similar 
organizations,  and  would  not  have  required  a Louisiana 
license  to  practice  medicine.  After  much  deliberation,  the 
committee  decided  that  there  was  not  enough  value  to 
the  LSMS  to  implement  this  new  category.  The  BOG  also 
directed  the  committee  to  study  Resolution  98-114, 
regarding  methods  to  improve  membership  recruitment 
and  retention.  The  committee  approved  three  motions 
regarding  Resolution  98-114:  1)  that  there  is  no  need  to 
divide  the  Department  of  Membership  and  Finance,  2) 
that  the  committee  will  continue  to  develop  and 
implement  a joint  membership  recruitment  and  retention 
plan  to  benefit  the  LSMS  and  component  societies,  and  3) 
that  the  committee  will  continue  to  study  the  possibility 
of  hiring  additional  staff  to  enhance  member  services  and 
outreach  to  non-members. 

The  committee  studied  and  approved  a proposal  from 
David  Post,  MD,  to  form  a rural  caucus  for  component 
societies.  The  formation  of  the  caucus  is  designed  to 
enable  smaller  component  societies  to  meet  to  discuss 
issues  in  healthcare  primarily  affecting  rural  areas  of  the 
state,  and  to  give  them  a voice  to  air  their  concerns  about 
these  issues.  After  review  by  the  BOG,  the  proposal  was 
sent  to  the  House  of  Delegates  as  Resolution  99-110,  where 
it  was  adopted.  The  committee  also  approved  motions 
to  implement  a recognition-based  peer-to-peer 
recruitment  program  to  stimulate  physician  participation 
in  recruitment  of  members,  and  to  develop  an  LSMS 
membership  lapel  pin.  An  additional  recruitment  and 
retention  assistance  program  was  also  approved,  which 
offers  rebates  to  component  societies  for  timely 
submission  of  LSMS  dues.  This  program  will  be  offered 
as  an  alternative  to  the  existing  recruitment  and  retention 


program  that  offers  a certain  amount  per  member  to  those 
societies  requesting  the  funds.  These  motions  were 
approved  by  the  Board  of  Governors,  and  the  programs 
are  in  place  to  assist  both  physicians  and  components  in 
recruiting  new  members  to  the  Society. 

The  committee  also  approved  a motion  to  develop  a 
program  to  focus  on  retention  of  new  active  members 
within  each  of  their  first  three  years  of  membership,  in 
order  to  maintain  their  interest  in  organized  medicine, 
and  to  obtain  feedback  from  them  regarding  issues  they 
would  like  to  see  discussed.  Staff  is  working  on  the  new 
programs  and  will  have  them  ready  for  the  Year  2000 
recruitment  and  retention  campaigns.  The  department 
is  also  currently  working  on  the  development  of  a society- 
sponsored  health  insurance  program  as  a member  benefit. 
This  topic  will  be  presented  to  the  Insurance  Committee 
and  the  Membership  Committee  for  study.  The 
department  also  attempted  to  hold  a Membership  Summit 
during  1999. 

At  the  beginning  of  1999,  the  Society  leadership 
realized  that  the  upcoming  legislative  session  was  going 
to  be  extremely  busy  in  terms  of  its  impact  on  healthcare 
and  physicians.  The  Budget  and  Finance  Committee  was 
asked  to  comment  on  the  possibility  of  hiring  additional 
contract  lobbyists  to  deal  with  the  hectic  session.  The 
committee  approved  a motion  to  recommend  the  use  of 
undesignated  reserves  to  provide  for  the  hiring  of  two 
contract  lobbyists.  The  committee  also  recommended  that 
the  BOG  discuss  the  necessity  of  funding  for  additional 
lobbyists  for  future  legislative  sessions. 

The  committee  instructed  staff  to  obtain  requests  for 
proposals  regarding  custody  and  management  of  the 
LSMS'  investment  portfolios.  These  were  obtained  from 
a number  of  institutions,  and  were  presented  to  the 
committee.  Those  firms  responding  were  Merrill  Lynch, 
Salomon-Smith  Barney,  Paine  Webber,  Hancock  Bank, 
Whitney  National  Bank,  and  JMC  Capital  Management. 
After  extensive  discussion  and  analysis  of  the  proposals, 
the  committee  instructed  staff  to  obtain  clarification  of 
several  of  the  proposals  by  separating  custody  expenses 
from  investment  / management  expenses.  The  committee 
also  felt  that  it  would  be  advantageous  to  wait  until  after 
the  Year  2000  rollover  to  make  any  decisions  regarding 
changing  custody  and  management  of  the  investments. 

The  committee  met  during  the  summer  to  develop 
the  Fiscal  Year  2000  budget.  In  preparation,  the  committee 
reviewed  extensively  the  current  and  past  two  years' 
financial  statements.  Over  the  preceding  two  years, 
revenue  from  active  dues  has  been  lower  than  forecast, 
and  was  also  at  the  end  of  1999.  The  committee  decided 
to  use  actual  1999  dues  receipts  to  project  active  dues 
revenue  for  FY  2000,  in  order  to  establish  a more  realistic 
base  for  development  of  the  budget.  The  committee 
determined  that  a realistic  estimate  of  active  dues  for  FY 


Supplement  44  VOL  152  March  2000  J La  State  Med  Soc 


2000  is  $1,687,500,  based  on  an  active  membership  of  4,500 
physicians.  The  committee  also  spent  much  effort 
determining  a realistic  earnings  estimate  for  the 
investment  portfolio.  The  conclusion  of  the  committee 
was  an  earnings  estimate  of  $325,000.  The  resulting 
budget  was  still  approximately  $95,000  out  of  balance 
when  it  was  presented  to  the  Board  of  Governors  at  the 
September  meeting.  The  Board  made  several 
amendments  to  balance  the  budget,  which  was  presented 
to  the  House  of  Delegates  and  approved. 

In  other  actions,  the  committee  approved  a 
recommendation  that  the  BOG  establish  a policy  to  collect 
a monetary  penalty  from  a component  society  that  collects 
and  holds  dues  beyond  the  February  1 delinquency  date 
for  LSMS  dues.  The  BOG  voted  not  to  take  any  action  on 
this  recommendation.  The  committee  also  revised  the 
reimbursement  policies  of  the  LSMS,  in  order  to  clarify 
payment  policies  for  committee  meeting  attendance  and 
BOG  meetings.  These  were  presented  to  the  Board  and 
accepted.  The  committee  also  approved  a motion  to 
reimburse  the  expenses  of  the  AMA  Past-President  for 
attendance  at  the  1999  AMA  Interim  Meeting,  at  the  same 
per  diem  rate  as  other  members  of  the  AMA  Delegation. 
The  committee  referred  back  to  the  BOG  the  subject  of 
reimbursement  of  expenses  of  the  LSMS  President  for 
contributions  for  political  purposes.  The  subject  of  joint 
sponsorship  of  specialty  society  social  functions  with 
legislators  was  also  referred  back  for  development  of 
guidelines  so  that  the  committee  might  evaluate  the  fiscal 
impact. 

The  Insurance  Committee  handled  a request  from  the 
St.  Paul  Insurance  Company  for  a rate  increase.  The  St. 
Paul  claims  that  the  severity  of  claims  for  their  company, 
while  lower  than  the  national  average,  is  a higher  than 
average  as  a percentage  of  the  $100,000  cap  in  Louisiana. 
St.  Paul  also  claims  that  frequency  and  loss  per  physician 
in  Louisiana  are  higher  than  the  national  average.  The 
committee  expressed  its  concern  that  the  problem  may 
be  an  anomaly  as  other  carriers  are  not  experiencing  the 
same  claims  experience.  It  is  the  policy  of  the  LSMS  to 
oppose,  as  a matter  of  principle,  any  unjustified  rate 
increase  request. 

Although  membership  was  down  in  1999,  the  Society 
is  still  financially  healthy.  The  LSMS  has  gained  many 
resident  and  medical  student  members.  The  department 
will  continue  to  try  to  implement  proven  programs  to 
recruit  and  retain  new  members,  and  will  examine  and 
implement  membership  services  that  are  of  value  to  our 
members. 

Bryan  LaHaye 
Director  of  Membership  and  Finance 


DEPARTMENT  OF  PUBLIC  AFFAIRS 

The  Department  of  Public  Affairs  continued  pursuing  new 
and  innovative  public  relations  and  communications 
efforts  on  behalf  of  the  Louisiana  State  Medical  Society 
and  its  membership  throughout  1999. 

Responsible  for  all  publications  of  the  LSMS,  staff  from 
this  department  continually  looked  for  new  ways  to 
provide  improved  content  and  design  of  the  society's 
major,  regular  publications,  the  Journal  of  the  Louisiana 
State  Medical  Society , the  Capsules  newsletter,  and  the 
annual  LSMS  Membership  and  Resource  Directory. 
Special  issues  of  the  Journal  for  1999  included:  the  LSMS 
Annual  Report  Issue,  Cancer  in  Louisiana,  Heart  Disease 
in  Louisiana,  and  School-Based  Health.  This  year  also  saw 
the  continuance  of  a regular  column  in  the  Journal  written 
by  the  current  LSMS  president  to  keep  members  informed 
of  importance  issues.  In  cooperation  with  the  Committee 
on  Pediatric  Health,  the  department  focused  the  October 
issue  of  Capsules  on  Child  Health  issues  and,  in  addition, 
a number  of  positive  changes  were  implemented  in  the 
Membership  and  Resource  Directory  to  make  it  even  more 
useful  as  a resource  tool. 

In  addition,  staff  worked  on  a number  of  other 
publications,  including  special  bulletins,  news  releases, 
meeting  announcements  and  brochures,  medical  student 
and  resident  directories,  the  Legislative  Summary,  and 
the  Executive  Memo. 

A major  portion  of  staff  time  this  year  was  devoted  to 
activities  surrounding  the  successful  re-election  campaign 
of  LSMS  member  Donald  J.  Palmisano,  M.D.,  to  the 
American  Medical  Association  Board  of  Trustees.  Four 
special  issues  of  The  Pelican , the  campaign  newsletter  of 
the  LSMS,  were  published  and  sent  to  all  AMA  delegates 
across  the  nation,  and  a number  of  other  special  campaign 
materials  were  developed  and  distributed  by  this 
department.  PA  staff  also  organized  numerous  activities 
for  the  campaign,  including  the  ever-popular  LSMS 
Gumbo  Party,  held  during  the  AMA  annual  meeting  in 
Chicago  in  June.  We  are  proud  to  report  that  not  only 
was  Dr.  Palmisano  re-elected  to  the  Board,  he  was  the 
overwhelming  favorite,  receiving  more  votes  than  any 
other  candidate. 

The  LSMS  web  site,  www.lsms.org,  was  also  a top 
priority  for  the  Department  of  Public  Affairs  this  year. 
Staff  took  over  full-time  duties  of  maintaining  the  content 
and  information  posted  on  the  web  site,  including  the 
addition  of  the  Legislative  section,  which  carried  daily 
updates  of  the  activities  of  the  1999  Louisiana  Legislature. 
This  activity  brought  tremendous  positive  response  from 
LSMS  members,  as  well  as  other  site  visitors  and  was  used 
as  a model  example  to  other  states.  By  keeping  up-dated 
via  the  web  site,  LSMS  members  could  take  immediate 
action  as  needed  to  voice  their  support  or  opposition  for 
important  bills  relating  to  medicine  and  physicians.  This 


Supplement  45  VOL  152  March  2000  J La  State  Med  Soc 


activity  was  deemed  very  useful  in  bringing  about  a 
number  of  LSMS  successes  at  the  Legislature  this  year. 
Additionally,  the  LSMS  Alliance  section  of  the  web  site 
was  revamped  in  cooperation  with  Alliance  President 
Karen  Depp  and  received  numerous  accolades  from  other 
state  alliance  organizations.  Plans  began  near  the  end  of 
the  year  to  implement  some  major  design  and  content 
changes  to  the  site  to  make  it  more  user-friendly  and 
informative,  and  it  is  anticipated  those  changes  will  evolve 
throughout  2000. 

Public  Affairs  staff  assisted  in  the  planning  and 
implementation  of  a number  of  special  events  this  year, 
including  the  1999  Leadership  Conference  in  January.  The 
department  organized  the  special  session  on  media 
relations  which  proved  to  be  one  of  the  most  informative 
- and  entertaining  - sessions  of  the  conference.  The 
exhibitor  display  at  the  LSMS  House  of  Delegates  Annual 
Meeting  in  October  was  very  successfully  coordinated  by 
this  department  in  1999  and  brought  in  a number  of  new 
and  returning  interesting  and  informative  vendors. 

Continuing  to  work  with  five  of  the  LSMS  committees 
kept  staff  busy  throughout  the  year.  With  the  cooperation 
of  the  Committee  on  Public  Relations,  the  staff  oversaw 
the  annual  Medicine  and  Religion  Breakfast  in  October, 
the  annual  Excellence  in  Media  Awards  contest  in 
September,  the  society's  participation  in  the  Louisiana 
Science  and  Engineering  Fair  in  April,  the  development 
and  distribution  of  regular  news  releases,  and  conducted 
a survey  of  component  society  communications  activities. 
Staff  also  worked  with  the  Committee  on  Physician/ 
Patient  Advocacy,  the  Committee  on  Pediatric  Health,  the 
Committee  on  Public  Health,  and  the  Committee  on 
Maternal  and  Perinatal  Health  on  numerous  activities. 

Publications  Coordinator  duties  were  shared  this  year 
by  Charlotte  Cavell  and  by  Candace  Davis,  who  came  to 
the  LSMS  half-way  through  the  year  when  Charlotte  left 
to  pursue  other  career  opportunities. 

The  Department  also  continues  to  be  very  fortunate 
to  have  Administrative  Assistant  Melissa  Cantrell  on  staff. 
Melissa  took  on  a number  of  new  and  additional  duties 
this  year  and  is  a very  talented,  dedicated,  and  valued 
member  of  the  PA  team.  We  are  extremely  proud  to  note 
that  this  is  evidenced  not  only  by  our  own  recognition 
and  appreciation  of  her  efforts,  but  was  echoed  this  year 
by  many  others,  as  Melissa  was  named  by  her  fellow 
employees  as  the  1999  LSMS  Employee  of  the  Year. 

The  Department  of  Public  Affairs  looks  forward  to 
the  opportunity  to  provide  continued  and  improved 
service  to  our  membership  as,  together,  we  face  the  many 
changes  and  challenges  that  the  year  2000  will  bring. 

Cathy  Lewis 
Director  of  Public  Affairs 


PHYSICIANS’  HEALTH  FOUNDATION 
OF  LOUISIANA 

PHYSICIANS’  HEALTH  PROGRAM 

Nineteen  ninety-nine  was  a year  of  tremendous 
accomplishment  for  the  Physicians'  Health  Program 
(PHP).  As  indicated  in  the  1998  Annual  Report,  the 
structure  and  function  of  the  entire  program  was  changed 
to  improve  the  PHPs  ability  to  effectively  monitor  and 
advocate  for  impaired  physicians.  Almost  every  goal 
envisioned  by  the  PHP,  the  Physicians'  Health  Committee 
(PHC)  and  the  PHP  Medical  Director  was  realized  in  1999. 
Many  of  these  goals  were  years  in  the  making,  which 
makes  their  accomplishment  that  much  more  meaningful, 
even  more  so  when  the  entire  transformation  was 
accomplished  in  just  over  one  year. 

As  previously  reported  in  the  1998  Annual  Report, 
the  PHP  was  officially  relocated  from  the  Louisiana  State 
Medical  Society  (LSMS)  to  the  Physicians'  Health 
Foundation  of  Louisiana  (PHFL),  as  was  the  Physicians' 
Health  Committee  (PHC).  At  the  time  of  the  previous 
annual  report,  the  PHFL  was  waiting  to  receive  notice 
from  the  IRS  regarding  its  request  for  tax-exempt  status. 
The  IRS  granted  the  PHP  tax-exempt  status  in  1999. 

The  PHC  met  three  times  in  1999,  as  in  1998,  and 
continued  to  lay  the  framework  and  foundation  for  a 
strong  and  successful  program.  The  first  of  these 
accomplishments  was  the  implementation  of  a statewide 
random  drug-testing  program.  The  PHP  executed  a 
professional  service  agreement  with  Professional 
Recovery  Network  (PRN)  to  provide  for  testing  of  all  PHP 
participants  required  to  remain  abstinent  from  substance 
use.  This  drug-testing  program  became  effective  on  July 
1,  1999. 

Under  the  new  program,  each  participant  is  assigned 
a color,  which  reflects  the  frequency  of  their  testing.  Each 
participant  is  required  to  phone  in  to  an  "800"  number 
Monday  through  Friday  to  determine  if  their  color  has 
been  selected,  and  if  so,  they  must  then  submit  a sample 
for  testing.  Testing  frequencies  are  on  average  weekly 
for  the  first  six  months  of  the  contract,  every  other  week 
for  the  subsequent  18  months  (until  the  end  of  year  two 
of  the  contract),  monthly  for  the  third  year  of  the  contract 
and  every  other  week  for  years  four  and  five  of  the 
contract.  In  addition,  the  colors  are  selected  in  a truly 
random  fashion,  which  means  that  the  participants  may 
be  tested  two  days  in  a row,  or  tested  once  and  not  tested 
again  for  a week  or  other  period  of  time.  Thus,  there  is 
little  to  no  predictability  of  testing.  PRN  has  arranged 
for  collection  sites  throughout  the  state  and  has  added 
additional  sites  to  accommodate  the  participants.  The 
"Recovery  Panel"  tests  for  28  drugs  in  13  drug  classes. 
Drugs  not  included  in  this  panel  are  added  once  they  have 
been  identified  as  a drug  of  choice.  All  initial  screens  are 


Supplement  46  VOL  152  March  2000  J La  State  Med  Soc 


by  immunoassay  and  all  confirmations  are  by  gas 
chromatography/ mass  spectrometry  (GC/MS).  To  date, 
the  new  drug-testing  program  has  proven  to  be  very 
effective. 

Additionally,  the  PHP  implemented  new  treatment 
contracts,  which  were  developed  in  1998.  As  you  may 
recall  from  the  1998  annual  report,  the  contracts  were 
revised  to  address  all  impairment  types  and  to  reflect  the 
new  program  requirements.  A total  of  73  contracts  were 
executed  by  all,  then  current,  PHP  participants,  with  the 
exception  of  those  participants  who  were  in  the  fifth  year 
of  their  contract  with  less  than  six  months  remaining. 
These  contracts  were  retroactive  to  the  effective  date  of 
all  previous  contracts  and  were  not  new  five-year 
contracts.  The  contract  only  amended  the  program 
requirements,  which  changed  under  the  new  program. 

The  PHP  also  implemented  its  new  monitoring 
program  in  1999.  As  you  may  recall  from  the  1998  annual 
report,  the  responsibility  for  monitoring  was  transferred 
from  the  Component  Medical  Society  PHC  level  to  the 
PHFL  level,  thereby  centralizing  all  monitoring  functions. 
The  new  monitoring  program  requires  each  participant 
to  have  monitoring  forms  reflecting  their  compliance  with 
contract  requirements  forwarded  to  the  PHP 
Administrative  and  Medical  Directors.  Both  directors 
review  the  forms  for  compliance.  Since  implementing  the 
new  monitoring  program,  the  participants  and  their 
treating  professionals  have  routinely  forwarded  these 
monitoring  forms  and  provided  the  PHP  with  the 
necessary  documentation  of  their  compliance. 

As  a result  of  the  implementation  of  the  new  treatment 
contracts,  the  new  monitoring  program  and  the  new  drug- 
testing program,  every  PHP  participant  is  effectively  being 
monitored  according  to  reasonably  high  standards,  while 
simultaneously  strengthening  the  credibility  of  the 
program  and  increasing  the  PHPs  ability  to  advocate  on 
behalf  of  its  participants. 

As  mentioned  previously,  the  PHP  has  developed  and 
installed  a "Case  Management"  database  to  track  the 
information  contained  in  the  monitoring  forms  being 
forwarded  to  the  PHFL  headquarters.  This  database  was 
specifically  designed  to  reflect  the  requirements  of  the 
program  (i.e.  Aftercare,  AA/NA  meetings,  Caduceus 
meetings,  therapy,  psychiatrist  visits,  continuing  medical 
education,  and  drug-testing)  and  to  enable  the  PHP  to 
easily  manage  each  participant7  case.  The  database  can 
provide  a myriad  of  reports,  which  will  enable  the  PHP 
to  make  accurate  and  efficient  determinations  as  to  a 
participant'  compliance. 

Also  mentioned  in  the  1998  annual  report,  the 
Memorandum  of  Understanding  between  the  Louisiana 
State  Medical  Society  (LSMS)  and  the  Louisiana  State 
Board  of  Medical  Examiners  (LSBME)  was  revised  to 
reflect  the  move  into  the  PHFL  and  the  new  program 


structure  and  function.  At  its  December  15, 1999  meeting, 
the  LSBME  voted  to  approve  the  new  Memorandum.  The 
PHFL  is  in  the  process  of  reviewing  the  new 
Memorandum  and  hopes  to  reach  an  agreement  with  the 
LSBME  very  soon. 

The  objectives  outlined  in  the  strategic  plan  referenced 
in  the  1998  annual  report  were  also  achieved.  PHP 
Administrative  Director,  Michael  DeCaire,  conducted 
orientations  at  component  medical  societies  and  their 
respective  PHCs,  regarding  the  changes  to  the  program 
and  their  roles  under  the  new  program.  In  addition,  Mr. 
DeCaire  conducted  orientations  at  various  hospitals 
throughout  the  state  with  their  medical  staffs, 
credentialing  committees,  and  medical  executive 
committees,  to  increase  awareness  of  the  PHP  and  to 
demonstrate  the  value  that  these  hospitals  derive  from 
the  PHPs  monitoring.  These  hospitals  were  very  receptive 
to  the  PHP  and  have  already  demonstrated  their  support, 
by  making  referrals.  Mr.  DeCaire  will  continue  these 
efforts  on  an  ongoing  basis  and  has  recently  been  invited 
to  make  a presentation  at  the  Louisiana  Medical  Group 
Management  Association  (LMGMA)  Annual  Conference 
on  March  30,  2000. 

Furthermore,  the  PHP  has  developed  extensive  fund 
raising  efforts  as  indicated  in  the  1998  Annual  Report  as 
the  third  phase  of  the  strategic  plan.  As  you  may  recall, 
the  initial  intention  of  the  LSMS  was  to  provide  the  PHFL 
with  funds  sufficient  to  cover  the  costs  associated  with 
the  start-up  of  the  foundation.  Then,  at  some  point,  the 
PHFL  would  generate  funds  sufficient  to  cover  its  own 
costs.  These  fund-raising  efforts  began  with  the  1999 
LSMS  House  of  Delegates,  whereby  a resolution  by  the 
PHC  to  seek  legislation  allowing  for  the  addition  of  a fee 
of  up  to  twenty-five  dollars  per  year,  to  the  existing  license 
fee  was  approved.  The  LSMS  will  introduce  this 
legislation  in  the  2000  fiscal  session.  In  addition,  the  PPIFL 
has  prepared  additional  fund-raising  campaigns,  which 
will  begin  in  early  2000.  These  campaigns  include  annual 
requests  for  donations  from  previous  and  current 
participants  who  may  have  derived  some  benefit  from 
participation  in  the  PHP  and/ or  its  advocacy  efforts  on 
their  behalf.  Also  included  are  hospitals  which  employ 
or  staff  PHP  participants  who  may  have  benefited  from 
the  monitoring  provided  by  the  PHP.  Furthermore,  the 
PHFL  will  request  annual  donations  from  medical 
malpractice  carriers  who  may  also  benefit  from  the 
monitoring  provided  by  the  PHP.  Lastly,  the  PHFL  will 
request  donations  from  pharmaceutical  companies  and 
various  other  private  sources  of  potential  funding.  In 
addition,  the  PHFL  may  apply  for  federal  domestic 
assistance  in  the  form  of  drug  abuse  research  grants  if 
necessary.  All  of  these  funds  will  be  used  to  conduct 
research  on  physician  impairment,  assist  qualifying 
participants  with  evaluation  and  / or  treatment  expenses. 


Supplement  47  VOL  152  March  2000  J La  State  Med  Soc 


drug  testing,  monitoring,  and  continuing  medical 
education.  These  funds  will  also  be  used  for  staffing  the 
PHFL  as  well  as  operating  expenses. 

Although  not  included  as  a part  of  the  1999  strategic 
plan,  the  PHFL  PHP  hosted  the  Southeast  Region  of  State 
Physician  Health  Programs  Annual  Meeting  on 
November  12-13, 1999.  The  meeting  was  held  at  the  New 
Orleans  Marriott  and  was  attended  by  medical  and 
executive  directors  from  the  ten  states  comprising  the 
southeast  region.  In  addition,  the  Federation  of  State 
Physician  Health  Programs  President  and  Board  of 
Directors  were  in  attendance.  Attendees  participated  in 
a three-hour  round-table  discussion,  panel  discussions 
and  presentations,  which  were  focused  on  issues  that 
PHPs  in  the  southeast  region  currently  face.  The  meeting 
was  quite  a success  and  gave  the  PHFL  PHP  some  national 
recognition. 

The  PHFL  PHP  accomplished  a great  deal  in  1999  in 
addition  to  the  basic  core  functions  of  receiving  reports, 
referring  for  evaluation  and  / or  treatment,  execution  of 
treatment  contracts  and  monitoring  compliance.  The 
program  continued  to  grow  in  the  midst  of  all  of  these 
changes.  There  are  103  participants  currently  in  the 
program.  Approximately  80%  are  substance  abuse/ 
chemical  dependency,  6%  are  psychiatric  illness  and  15% 
are  dual  diagnosis.  There  are  currently  no  participants 
who  have  either  a physical  limitation  or  disruptive 
behavior.  Chart  1 reflects  these  figures. 


In  1999,  the  PHP  received  a total  of  72  reports  of 
impaired  physicians.  Thirty  executed  a treatment  contract 
and  enrolled  in  the  PHP.  Chart  2 depicts  the  number  of 
new  contracts  executed  by  year. 


NUMBER  OF  NEW  CONTRACTS  BY  YEAR 


CHART  2 


Fifteen  chose  not  to  follow  the  recommendations  of 
the  PHP  and  were  forwarded  to  the  LSBME,  in  accordance 
with  the  Memorandum  of  Understanding.  Thirteen  are 
currently  under  long  term  observation.  Eight  are 
currently  in  the  information  gathering  phase,  while  2 are 
being  evaluated,  3 are  in  treatment,  and  1 will  execute  a 
contract  once  the  discharge  records  are  received.  Table  1 
reflects  these  figures. 


CONTRACT  TYPE 


CHART  1 


TABLE  1 

Number  of  Reports  received 

72 

Information  collection  (No  action  taken  yet)  8 

BCD 

Receiving  evaluation 

2 

E3  PSYCH 
□ DUAL 

Receiving  treatment 

3 

□ DIS.  BEH. 

Treatment  concluded* 

1 

Executed  treatment  contract 

30 

Referred  to  the  LSBME 

15 

Long  term  observation 

13 

* Treatment  contract  will  be  executed  upon 

receipt  of  discharge  recommendations 

Supplement  48  VOL  152  March  2000  J La  State  Med  Soc 


As  illustrated  in  Chart  3,  43%  of  participants  have 
been  ordered  by  the  LSBME  to  participate  in  the  PHP, 
while  57%  are  voluntary. 


PARTICIPANTS  ORDERED  BY  LSBME  AS  A PERCENTAGE 


Thirty-five  percent  are  LSMS  members,  while  65%  are 
not  members  of  the  LSMS.  See  Chart  4. 


PARTICIPANTS  WHO  ARE  LSMS  MEMBERS  BY  PERCENTAGE 


In  closing,  1999  has  been  an  extraordinary  year  for 
the  PHP,  watching  the  vision  turn  into  a reality.  The  PHFL 
looks  forward  to  2000  and  thanks  all  of  those  who  were 
instrumental  in  the  PPIPs  accomplishments  during  this 
past  year. 


Michael  R.  DeCaire 
Administrative  Director 


Supplement  49  VOL  152  March  2000  J La  State  Med  Soc 


Reports  of  Committees 


The  following  committees  submitted  an  annual 
report  of  activities  for  1999  to  the  LSMS  House 
of  Delegates.  Copies  of  the  reports  are  available 
upon  request  from  the  LSMS  Headquarters. 

• Chronic  Diseases 
• CME  Accreditation 

• Disaster  and  Emergency  Medical  Services 
• Evolving  Trends  in  Medicine 
• Federal  Legislation 
• Geriatrics 
• Hall  of  Fame 
• Insurance 

• Liaison  with  Health  Professionals 


Maternal  and  Perinatal  Health 

Medical  Education 

Medical  / Legal  Interprofessional 

Membership 

Mental  Illness  and  Substance  Abuse  Disorders 

Pediatric  Health 

Physician's  Health 

Physician  / Patient  Advocacy 

Public  Health 

Public  Relations 

Sports  Medicine 


The  reports  of  the  Budget  and  Finance  Committee  and  the  Council  on  Legislation  are  included  in  this  Annual  Report. 


Proceedings  of  the  HOD 


PROCEEDINGS  OF  THE  HOUSE  OF  DELEGATES 
120th  ANNUAL  MEETING 
October  21  -23, 1999 

Call  to  Order 

K.  Barton  Farris,  MD,  Speaker  of  the  House  called  the 
opening  session  of  the  Annual  Meeting  to  order  at  9:00 
a.m.  on  Friday,  October  22,  1999  in  the  Premier  I & II 
Ballrooms  of  the  Radisson  Hotel  and  Conference  Center 
in  Baton  Rouge,  Louisiana.  At  the  invitation  of  Leo 
Lowentritt,  Jr.,  MD,  President,  Rabbi  Arnold  Task  of 
Temple  Gemiluth  Chassodim  in  Alexandria  offered  the 
invocation.  Colors  were  presented  by  the  Headquarters 
company,  769th  Engineers  Battalion  of  the  Louisiana  Army 
National  Guard,  followed  by  the  Pledge  of  Allegiance  by 
the  entire  assembly. 

Recognition  of  Deceased  LSMS  Members 

Wallace  H.  Dunlap,  MD,  Secretary-Treasurer,  recited  the 
names  of  LSMS  members  deceased  since  the  last  Annual 


Meeting.  All  present  stood  in  memory  for  those  deceased 
colleagues. 

Recognition  of  New  Delegates 

Russell  Klein,  MD,  Vice  Speaker  of  the  House  requested 
all  new  delegates  introduce  themselves  and  indicate  the 
society  they  were  representing. 

Remarks  of  the  Speaker 

K.  Barton  Farris,  MD,  Speaker  of  the  House  reviewed  the 
process  by  which  resolutions  are  numbered  and 
categorized  prior  to  the  Annual  Meeting.  He  reiterated 
to  the  House  his  assurances  that  the  only  changes  that 
are  made  by  the  Speakers  to  resolutions  prior  to  their 
introduction  to  the  House  were  grammatical  or 
procedural  in  nature. 

Dr.  Farris  noted  that  the  procedure  of  displaying 
amendments  to  resolutions  on  projection  screens  would 
be  utilized  again  as  a means  of  making  changes  in 
language  clearer  to  all  delegates  prior  to  final  voting. 


Supplement  50  VOL  152  March  2000  J La  State  Med  Soc 


However,  he  emphasized  the  need  for  all  amendments  to 
be  written  on  the  appropriate  forms  and  given  to  the 
Speakers  who  will,  in  turn,  give  them  to  the  staff  for 
posting  on  the  screens.  He  also  reminded  the  House  that 
amendments  must  be  moved  by  a member  on  the  floor 
before  they  can  be  introduced  for  consideration;  merely 
handing  in  the  amendment  forms  to  the  Speakers  or  staff 
does  not  constitute  a motion  to  introduce  the  amendment. 

The  Speakers  announced  that  a consent  calendar  was 
being  utilized  for  this  meeting  as  a means  of  speeding  up 
the  consideration  of  resolutions.  Dr.  Farris  listed  those 
resolutions  which  the  Speakers  had  placed  on  the  consent 
calendar  and  stated  that  if  any  delegate  wished  to  debate 
a resolution  on  the  calendar,  that  delegate  needed  to  move 
that  it  be  extracted  from  the  consent  calendar.  The  consent 
calendar  of  remaining  resolutions  would  then  be  voted 
on  as  a single  group. 

Remarks  of  the  President 

Leo  L.  Lowentritt,  Jr.,  MD,  President,  addressed  the  House 
on  the  activities  and  accomplishments  during  his  term  as 
President.  (A  copy  of  the  Presidential  Address  is  appended 
to  these  proceedings.) 

Report  of  the  Credentials  Committee 

Vincent  Culotta,  MD,  committee  member,  reported  that 
a quorum  of  duly  certified  delegates  was  present  and 
seated. 

Report  of  the  Committee  on  Rules  and  Order  of 
Business 

Joseph  Brenner,  MD,  Chair,  presented  the  report  of  the 
Committee  on  Rules  and  Order  of  Business.  The 
committee  recommended  the  following  rules  for  use  by 
the  1999  House  of  Delegates: 

1.  Limitation  of  Debate:  Each  speaker  addressing  an 
item  brought  to  the  floor  for  a vote  is  limited  to  three 
minutes  of  debate.  Each  delegate  may  return  to  the  floor 
for  one  minute  for  the  purpose  of  rebuttal  or  to  summarize 
his/her  position. 

2.  Late  Resolutions:  Dr.  Eugene  Worthen,  Chair,  Hall  of 
Fame  Committee  presented  a late  resolution  for 
consideration.  The  committee  recommended  the  House 
accept  the  resolution. 

3.  Official  Observers:  No  applications  were  received  to 
consider. 

4.  Substitute  Resolution  99-101:  The  Committee 
reviewed  resolution  99-101  and  prepared  a substitute  to 
be  submitted  to  the  House  at  the  appropriate  time. 

5.  Following  a request  from  the  Speakers,  the  Committee 
recommended  that  the  following  resolutions  be  taken  out 
of  order  and  considered  on  Friday  in  the  following  order: 


#99-413 

#99-405 

#99-302 

#99-307 

6.  The  Committee  recommended  that  an  index  of  all 
resolutions  be  included  in  the  handbook  for  delegate 
reference  and  to  use  as  a means  of  recording  the  actions 
of  the  House. 

The  Speaker  assigned  the  Worthen  resolution  number 

#121. 


Approval  of  the  Proceedings  of  the  1998  House  of 
Delegates 

The  Proceedings  of  the  Annual  Meeting  of  the  1998  House 
of  Delegates  were  approved  as  published. 

Approval  of  the  Actions  of  the  Board  of  Governors 
during  1998-1999 

The  actions  taken  by  the  Board  of  Governors  during  1998- 
1999  were  approved  as  presented.  Dr.  Klein  also  noted 
that  the  speakers  would  be  introducing  Resolution  #102 
which  addressed  certain  policies  passed  by  the  Board 
which  required  specific  approval  by  the  full  house.  Those 
policies  would  be  discussed  individually  at  the  time  the 
resolution  was  considered. 


Reports  Presented  to  the  House  of  Delegates  for  Note 
and  File 

Board  of  Governors 
Council  on  Legislation 
LSMS  Alliance 
AMA  Delegation 


Elections 

The  following  members  were  elected: 

Board  of  Governors 

President-Elect  Dudley  Stewart,  Jr.,  MD 

Vice  President  Keith  Desonier,  MD 

Speaker,  House  of  Delegates  K.  Barton  Farris,  MD 
Vice  Speaker,  House  of  Delegates 

Russell  C.  Klein,  MD 


Secretary-Treasurer 
First  District  Councilor 
Third  District  Councilor 
Fifth  District  Councilor 
Seventh  District  Councilor 
Ninth  District  Councilor 


Wallace  H.  Dunlap,  MD 
Vincent  Culotta,  MD 
Barry  G.  Landry,  MD 
Joseph  Busby,  Jr.,  MD 
R.  Mark  Williams,  MD 
Martin  J.  Ducote,  Jr.,  MD 
Laura  Bresnahan 


Medical  Student  Member 
Alternate  First  District  Councilor 

Floyd  Buras,  Jr.,  MD 
Alternate  Third  District  Councilor 

Walter  H.  Daniels,  MD 


Supplement  51  VOL  152  March  2000  J La  State  Med  Soc 


Alternate  Fifth  District  Councilor 

John  M.  Coats,  V,  MD 
Alternate  Seventh  District  Councilor 

Aretta  Rathmell,  MD 
Alternate  Ninth  District  Councilor 

Maximo  Lamarche,  MD 
Alternate  Student  Member  Drew  Baldwin 

AMA  Delegation 
Delegates 

Michael  S.  Ellis,  MD;  Jay  Shames,  MD;  Lawrence  M. 
Braud,  MD  (unexpired  term) 

Alternate  Delegates 

Carol  L.  Bayer,  MD;  Dudley  M.  Stewart,  Jr.,  MD; 
Student /Resident  Member,  Joshua  Lowentritt,  MD; 
Keith  Desonier,  MD  (unexpired  term) 

Council  on  Legislation  (three-year  term) 

Second  District  Councilor  Robert  Normand,  MD 

Third  District  Councilor  Walter  H.  Daniels,  MD 
Fifth  District  Councilor  Richard  I.  Ballard,  MD 

Eighth  District  Councilor  Richard  Norem,  MD 
Alternate  Second  District  Councilor 

Ralph  Katz,  MD 

Alternate  Third  District  Councilor 

Robert  Cazayoux,  MD 
Alternate  Fifth  District  Councilor 

Joseph  Busby,  MD 


Report  of  the  Budget  and  Finance  Committee 

Keith  Desonier,  MD,  member  of  the  Budget  and  Finance 
Committee  presented  the  report  of  the  Committee  and 
the  proposed  2000  budget  on  Friday.  On  Saturday,  Juan 
Watkins,  MD,  Vice-Chair  of  the  Budget  and  Finance 
Committee,  presented  the  budget  following  the  approval 
of  resolutions  with  fiscal  notes.  The  proposed  budget  was 
then  past  by  the  House.  The  approved  budget  is  attached 
to  these  proceedings. 


Report  of  the  Board  of  Medical  Examiners 

Elmo  Laborde,  MD,  Secretary-Treasurer  of  the  Board  of 
Medical  Examiners,  presented  a report  to  the  House 
concerning  the  activities  of  the  Board  for  the  last  year. 


Report  of  the  Secretary  of  the  Department  of  Health 
and  Hospitals 

David  Hood,  Secretary  of  the  Louisiana  Department  of 
Health  and  Hospitals  addressed  the  assembly  and 
provided  an  update  on  key  projects  and  activities. 

Remarks  by  US  Representative  John  Cooksey 

Following  a request  for  a point  of  personal  privilege  from 
Donald  Palmisano,  MD,  the  Speaker  invited  the 
Honorable  John  Cooksey,  Representative  for  District  5, 
US  House  of  Representatives,  to  come  to  the  podium  and 
address  the  House. 


Approval  of  Bylaws  Amendments 

The  following  Bylaws  amendments  were  adopted, 
(language  deleted  is  shown  with  a strike-through  and  new 
language  is  indicated  in  bold  print) 

ARTICLE  VIII 

Life  of  Corporation  - How  to  Dissolve 

This  corporation  shall  exist  and  continue  for  a period  of 
ninety-nine  years,  in  perpetuity  unless  sooner  dissolved 
by  a two-third  vote  of  the  membership  present  and  voting, 
at  a meeting  specially  called  for  the  purpose  after  thirty 
days  notice.  In  case  of  such  a vote  dissolving  this 
corporation,  the  said  meeting  shall,  at  the  same  time  that 
such  vote  is  taken,  elect  three  liquidators  to  settle  and 
wind  up  its  affairs. 

As  specified  in  Article  IX  of  the  LSMS  Charter  an 
amendment  to  the  Charter  must  receive  a two-thirds  vote 
of  the  voting  members  registered  at  any  annual  meeting, 
provided  that  the  amendment  has  been  presented  at  a 
meeting  of  the  House  of  Delegate  at  the  previous  annual 
meeting,  and  such  amendment  has  been  officially  sent  to 
each  member,  district  society,  and  parish  society  at  least 
two  months  prior  to  the  meeting  at  which  final  action  is 
to  be  taken. 

Article  XXII.  Section  2.  C : 

C.  Travel  Expenses 

Reasonable  travel  expenses  for  the  following  shall  be  paid 
from  the  general  fund  upon  request  for  reimbursement: 

1.  Expenses  incurred  by  members  of  the  Board  of 
Governors  in  attending  meetings  of  the  Board  of 
Governors; 

2.  Expenses  incurred  by  delegates  and  alternate 
delegates  to  the  American  Medical  Association,  by  the 
Speaker  of  the  House  of  the  Louisiana  State  Medical 
Society,  by  the  President  and  the  President-elect  of  the 
Louisiana  State  Medical  Society  in  attending  official 
meetings  of  the  American  Medical  Association 

3.  Expenses  incurred  by  any  former  President  of  the 
AMA  from  Louisiana  in  attending  official  meetings  of 
the  AMA  House  of  Delegates  using  the  same 
allowance  and  criteria  as  determined  for  the 
individuals  listed  in  Article  XXII,  Section  2,  C.,  2.,  if 
such  expenses  are  not  otherwise  reimbursed,  subject 
to  the  approval  of  the  Board  of  Governors 

4.  3r  Expenses  incurred  by  the  President  in  the  discharge 
of  his  official  duties; 

5r-4 : Expenses  incurred  by  members  of  other  committees 
of  the  Louisiana  State  Medical  Society  or  the  House  of 
Delegates  in  attending  those  Committee  meetings;  and 


Supplement  52  VOL  152  March  2000  J La  State  Med  Soc 


6.  Expenses  incurred  by  office  personnel  and  other  society 
members  in  the  performance  of  specific  assignments. 

Article  IX.  Section  1.  A.  1: 

A.  Regular  Standing  Committees 

1.  Listing 
a:  Chronic  Diseases 

b.  CME  Accreditation 

c.  Disaster  and  Emergency  Medical  Services 

d.  Evolving  Trends  in  Medicine 

e.  Federal  Legislation 

f.  Geriatrics 

g.  Hall  of  Fame 

h.  Insurance 

i.  Liaison  with  Health  Professionals 

j.  Maternal  and  Perinatal  Health 

k.  Medical  Education 

l.  Medical /Legal  Interprofessional 

m.  Membership 

n.  Mental  Illness  and  Substance  Abuse 

o.  Pediatric  Health 
pr  Physicians7  Health 

p Physician-Patient  Advocacy 
tp  f.  Public  Health 
it  st  Public  Relations 
s.  tr  Sports  Medicine 
— t ut  Young  Physicians 

Article  III.  Paragraph  A.  Subparagraph  4 

4.  Must  be  a member  in  good  standing  in  a 
component  Parish  Society  ; the  Resident 

Section,  ordhe  Medical  Student  Section  and 

Article  III.  Paragraph  E.  Subparagraph  2 

2.  Must  maintain  his  membership  in  a component 
Parish  Society  the  Resident  Section,  or 
the  Medical  Student  Section 

Article  IV.  Section  4.  Paragraph  A.  Subparagraph  3 
2.  Must  be  a member  of  the  Resident  Section:  and 
a component  Parish  Society  of  their  choice. 

Article  IV.  Section  7.  Paragraph  A.  Subparagraph  2 

2.  Must  be  a member  of  the  Medical  Student  Section; 
and  a component  Parish  Society  of  their  choice; 

Article  IV.  Section  7.  Paragraph  B.  Subparagraph  3 

3.  Shall  have  the  right  to  vote  in  the  House  of  Delegates 
of  the  Louisiana  State  Medical  Society  only  if  he  is  a 
delegate  from  the  Medical  Student  Section  to  the  House 
of  Delegates. 

Article  IV.  Section  7.  Paragraph  C.  Subparagraph  1 
1.  Must  maintain  membership  in  the  Medical  Student 


Section;  and  a component  Parish  Society  of  their  choice; 

Article  XI,  Paragraph  A.  Subparagraph  9 

9.  One  Bdelegates,-or  one  alternate  delegates,  from  the 
residents  from  each  of  the  ACGME  accredited  training 
institutions  other  than  medical  schools  with  greater  than 
100  hundred  residents , if  appointed  by  the  Board  of 
Governors  after  consideration  of  recommendations  from 
the  Resident  Section;  and 

Article  XI.  Paragraph  A.  Subparagraph  10 

10.  One  delegates,  or  one  alternate  delegates-,  from  each 
medical  school  in  the  state,  if  appointed  by  the  Board  of 
Governors  after  consideration  of  recommendations  from 
the  Medical  Student  Section. 

Article  XV.  Paragraph  B 

B.  Delegates  to  the  House  of  Delegates  of  the  LSMS 
The  Resident  Section  submits  candidates  to  the  Board  of 
Governors  to  the  Louisiana  State  Medical  Society  who 
then  designates  three  delegates  and  three-alternate 
delegates  from  the  Resident  Section  to  serve  in  the  House 
of  Delegates  of  the  Louisiana  State  Medical  Society.  The 
designated  delegates  or  alternate  delegates  shall  have  the 
right  to  vote  in  the  House  of  Delegates  of  the  Louisiana 
State  Medical  Society. 

A resident  delegate  or  alternate  resident  delegate  of  the 
House  of  Delegates  shall  be  elected  to  a term  of  1 year. 

Article  XVI,  Paragraph  B 

B.  Delegates  to  the  House  of  Delegates  of  the  LSMS 
The  Medical  Student  Section  submits  candidates  to  the 
Board  of  Governors  of  the  Louisiana  State  Medical  Society 
who  then  designates  three-delegates  and  three-alternate 
delegates  from  the  Medical  Student  Section  to  serve  in 
the  House  of  Delegates  of  the  Louisiana  State  Medical 
Society.  The  designated  delegates  or  alternate  delegates 
shall  have  the  right  to  vote  in  the  House  of  Delegates  of 
the  Louisiana  State  Medical  Society. 

A medical  student  member  or  alternate  medical  student 
member  of  the  House  of  Delegates  shall  be  elected  to  a 
term  of  1 year. 

Article  XIX.  Paragraph  B 
B.  Members 

Membership  in  a Parish  Society  is  limited  to  those 
physicians  and  medical  students  within  the  named  parish, 
except  as  otherwise  stipulated  in  this  Subsection  B of 
Article  XIX. 

A member  may  shall  place  his  their  basic  parish  society 
membership  in  one  Parish  Society  only.  This  basic 
membership  may  be  either  (1)  in  the  Parish  Society  in 


Supplement  53  VOL  152  March  2000  J La  State  Med  Soc 


whose  jurisdiction  he  maintains  his  principal  office  or  (2) 
in  the  Parish  Society  in  whose  jurisdiction  he  maintains 
his  residence.  A medical  student  or  resident  member  shall 
place  their  basic  Parish  Society  membership  in  one  Parish 
Society  of  their  choice. 

(The  remainder  of  paragraph  B remains  unchanged.) 
Article  XIX.  Paragraph  E 

E.  Delegates  to  the  House  of  Delegates  of  the  LSMS 
A Parish  Society  is  entitled  to  send  delegates  to  the  House 
of  Delegates  of  the  Louisiana  State  Medical  Society. 

A delegate  must  be  a member  of  the  Louisiana  State 
Medical  Society. 

The  apportionment  of  delegates  from  a Parish  Society 
shall  be  one  delegate  and  one  alternate  delegate  for  each 
25  members  or  fraction  thereof  on  the  roster  of  active, 
dues-exempt,  and  academic,  and  resident  members  for 
that  Parish  Society  as  recorded  in  the  office  of  the 
Secretary-Treasurer  of  the  Louisiana  State  Medical  Society 
on  June  1 of  each  year.  In  July  of  each  year^  the- Secretary- 
Treasurer  of  the  Louisiana  State  Medical  Society  shall 
notify  each  Parish  Society  as-to  the-number -of-  delegates 
to  which  the  Parish  Society  is  entitled  for  the  current  year. 

Component  Parish  Societies  shall  have  one  additional 
delegate  and  one  alternate  delegate  for  each  200  resident 
members,  or  fraction  thereof,  in  their  societies.  These 
additional  delegates  must  be  residents  on  the  roster  of 
resident  members  for  that  Parish  Society  as  recorded  in  the 
office  of  the  Secretary-Treasurer  of  the  Louisiana  State 
Medical  Society  on  June  1 of  each  year. 

Component  Parish  Societies  shall  have  one  additional 
delegate  and  one  alternate  delegate  for  each  200  medical 
student  members , or  fraction  thereof  in  their  societies. 
These  additional  delegates  must  be  medical  students  on 
the  roster  of  medical  student  members  for  that  Parish 
Society  as  recorded  in  the  office  of  the  Secretary-Treasurer 
of  the  Louisiana  State  Medical  Society  on  June  1 of  each 
year. 

In  July  of  each  year,  the  Secretary-Treasurer  of  the 
Louisiana  State  Medical  Society  shall  notify  each  Parish 
Society  as  to  the  number  of  delegates  to  which  the  Parish 
Society  is  entitled  for  the  current  year. 

(The  remainder  of  paragraph  E remains  unchanged.) 

Article  XX.  Paragraph  B 

C.  Members 

Membership  in  a District  Society  is  limited  to  those 
physicians  and  medical  students,  who  are  members  of 


Parish  Societies  within  the  named  medical  district  as 
delimited  in  Subsection  F of  this  Article  XX. 

D.  (This  paragraph  remains  unchanged.) 

E.  (This  paragraph  remains  unchanged.) 

F.  (This  paragraph  remains  unchanged.) 

G.  Medical  Districts 

For  purpose  of  representation,  the  State  of  Louisiana  shall 
be  divided  into  the  following  Louisiana  State  Medical 
Society  medical  districts.  The  Board  of  Councilors  shall 
make  recommendations  for  the  composition  of  the 
districts  every  10  years  beginning  in  the  year  2001. 

Resolutions 

The  House  considered  resolutions  accepted  for  regular 
business  beginning  with  Section  A,  General  Business. 
Resolutions  acted  on  by  the  House  immediately  follow 
these  proceedings. 

House  of  Delegates  Special  Awards 

The  society's  Continuing  Education  Award  was  presented 
to  Journal  of  the  Louisiana  State  Medical  Society  editor 
Conway  S.  Magee,  MD  for  his  long-standing  support  and 
efforts  on  behalf  of  continuing  education  for  physicians 
in  Louisiana. 

One  LSMS  member  was  inducted  in  the  Society's  Hall 
of  Fame  for  1999.  Elmo  J.  Laborde,  MD  of  Lafayette,  who 
has  served  the  LSMS  in  a number  of  elected  and  appointed 
positions  since  joining  the  organization  20  years  ago.  Dr. 
Laborde  is  a current  member  and  Past  President  of  the 
Louisiana  State  Board  of  Medical  Examiners. 

Awards  Luncheon 

The  LSMS  presented  awards  and  offered  recognition  to 
outstanding  members,  journalists,  and  component  soci- 
eties. The  LSMS  Award  for  Excellence  in  Medical  Jour- 
nalism in  the  Print  Media  Category  was  presented  to  Jim 
Beam  of  the  American  Press  in  Lake  Charles.  Beam  was 
awarded  a $500  check  for  his  series  of  articles  on  prostate 
cancer.  The  winner  of  the  Award  for  Excellence  in  Medi- 
cal Journalism  in  the  Broadcast  Media  Category  was  Phil 
Rainier  of  WAFB-TV  in  Baton  Rouge.  The  $500  prize  was 
given  to  Rainier  for  his  special  report  titled,  "When  Sec- 
onds Count". 

Meritorious  Awards  for  Medical  Reporting  were  also 
presented.  The  award  for  Print  Media  went  to  Shannon 
Amidon  of  the  News- Star  of  Monroe  while  Steve  Coco  of 
KALB-TV  in  Alexandria  and  Margaret  Lawhon  of  Baton 
Rouge  received  the  awards  for  Broadcast  Media. 

The  LSMS  Continuing  Medical  Education  Award  was  pre- 
sented to  Ricardo  Martinez,  Jr.,  MD,  PhD,  of  Metairie  for 
his  work  in  promoting  continuing  medical  education  for 
physicians.  Dr.  Martinez  is  a founding  fellow  and  the 
current  president  of  the  American-Georgian  Academy  of 
Medicine  and  Surgery,  an  exchange  program  between 
LSU  Medical  Center  and  Tbilisis  Medical  Academy  of  the 


Supplement  54  VOL  152  March  2000  J La  State  Med  Soc 


Republic  of  Georgia.  The  academy  provides  professional 
medical  exchange  programs  and  initiatives. 

The  Louisiana  Medical  Political  Action  Committee 
(LAMPAC)  presented  Achievement  Awards  to  LSMS 
component  medical  societies  for  the  highest  number  and 
percentage  of  members  based  on  LSMS  membership 
totals.  This  award  went  to  Calcasieu,  St.  Landry, 
Natchitoches,  and  Avoyelles  Parish  Medical  Societies.  The 
1999  Founder's  Award  was  presented  for  another  year  to 
he  Orleans  Parish  Medical  Society  for  the  highest  number 
of  members. 

Inaugural  Banquet 

The  LSMS  recognized  those  members  who  had  reached 
their  50-year  anniversary  of  graduation  from  medical 
school.  A total  of  30  physicians  were  honored  and  eight, 
along  with  their  families,  were  present  to  receive  their 
50-year  pins. 


Installation  of  the  President 

Leo  L.  Lowentritt,  Jr.,  MD,  presented  the  gavel  to  Charles 
Clinton  Lewis,  Jr.,  MD  of  New  Iberia.  Dr.  Lewis  outlined 
his  goals  for  the  coming  year  in  an  address  to  members 
and  guests.  (A  copy  of  the  inaugural  address  is  apended 
to  these  proceedings.) 

Recognition  of  the  Past  President 

Dr.  Lewis  presented  the  Past  President's  pin  and  plaque 
to  Dr.  Lowentritt  in  recognition  of  his  service  as  President 
of  the  LSMS  during  1999. 

Adjournment 

There  being  no  further  business,  the  1999  Annual  Meeting 
of  the  House  of  Delegates  was  adjourned  at  3:00  p.m  on 
Saturday,  October  23,  1999. 


Dr.  Jay  Busby,  Jr.  listens  to 
House  debates. 


Past  Presdient  Dr.  Michael  S.  Ellis 
makes  a point  during  debate  on  a 
House  resolution. 


Dr.  Barry  Landry  submits  a 
resolution  change  to  LSMS  staff 
members  Ragan  Cannella  and 
Mary  DuCote. 


Dr.  Richard  Paddock  and  Dr.  Joshua 
Lowentritt  visit  with  exhibitors  during  a 
break  in  the  House  proceedings. 


Dr.  Clifton  Morris  of  the  Public  Relations 
Committee  presents  a merit  award  to 
Baton  Rouge  journalist  Margaret 
Lawhon. 


Supplement  55  VOL  152  March  2000  J La  State  Med  Soc 


Resolutions 


RESOLUTION  101 

Substitute  Resolution  Adopted  as  amended  - 10/22/99 
SUBJECT:  Sunset  Mechanism  for  House  of  Delegates 
Generated  Policy 

INTRODUCED  BY:  Committee  on  Rules  and  Order  of 
Business 

RESOLVED,  that  the  following  policies  of  the  LSMS  be 
reaffirmed: 

29.96  Encouraging  School  HIV  Education 

97.97  Good  Samaritan  Law 

96.96  Disposal  of  Toxic  Waste 

95.95  Access  to  Health  Care  for  the  Uninsured 

98.98  Mental  or  Nervous  Disorders  Insurance  Coverage 

97.97  Standards  of  Coverage  for  Private  Insurance 

97.97  Licensure  Fee  Exemption  for  Physicians  Over  Age 
75 

98.98  Continuing  Medical  Education 
85.85  Continued  LSMS  opposition  to  PROs 
91.91  Tanning  Parlors 

440.90  Education  on  the  Harmful  Effects  of  UVA  Light 
89.89  Tuberculosis  as  a Public  Health  Problem 
460.99  Public  Policy  on  Animal  Research 

95.95  "No  Smoking"  in  Public  Places 

505.98  Smoke-Free  Work  Environment 

98.98  Performance  Standards  for 
Mammography 

and  be  it  further 

RESOLVED,  that  the  following  policies  of  the  LSMS  be 
abandoned: 

95.95  Infectious  Medical  Waste 

93.93  Guidelines  for  Infectious  Medical  Waste 
Disposal  by  Physicians  Office 

88.88  Indigent  Health  Care 

99.99  Relative  Value  Scale 
and  be  it  further 

RESOLVED,  that  the  following  policies  of  the  LSMS  be 
amended  as  follows: 

20.93  Prevention  and  Control  of  AIDS:  The 

LSMS  accepts  the  following  recommendations  concerning 
the  prevention  and  control  of  AIDS: 

Recommendation  1:  That  the  LSMS  encourages 
government  implementation  of  the-reeommendations 
presented  by  President  Reagan's  Commission  on  AIDS. 

Recommendation  2:  That  the  LSMS  encourages 
the  AMA  to  continue  as  a catalyst  irrthe-  development  of 


public  service — advertisement  regarding  AIDS  in 
consultation  with  health  care,  community  and  government 
officials. 

Recommendation  3: — Tests  for  the  Human 
Immunodeficiency  Virus  (HIV)  should  be  readily  available 
to  all  who  wish  to  be  tested.  -The  tests  should  be  routinely 
subsidized  -for-individuals  who  cannot  afford  to  pay  the 
costs  of  their  test. 

Recommendation  4:  Testing  for  the  HIV  should  be 
mandatory  for  the  donors  of-blood  and  blood  fractions, 
organs  and  other  tissues  intended  for  transplantation  in 
the  United  States  or  abroad,  for  donors  of  semen  or  ova 
collected  for  artificiahmsemination  or  in  vitro  fertilization. 

Recommendation  5:  Voluntary  testing  should  be 
regularly  provided  for  the  following-types  -of-  individuals 
who  give  an  informed  consent: 

(1)  Patients  at  sexually  transmitted  disease  clinics. 

(2)  Patients  at  drug  abuse-clinics. 

(3)  Pregnant  women  in  high  risk  areas  in  the  first 
trimester  of  pregnancy 

(4)  Individuals  who  are  -from-areas  with  a high 
incidence  of  AIDS  or  who  engage  in  high  risk  behavior 
seeking  family- planning  services-: 

As  a matter  of  medical  judgment,  physicians  should 
encourage  voluntary  HIV  testing  for  individuals  whose 
history  of  clinical  status  warrant  this  measure. 

Recommendation  6:  That  the  LSMS  encourages  the 
DHHS  to  develop  an  accurate- reporting  mechanism -on  an 
anonymous — and — confidential  basis  with  enough 
information  to-be  epidemiologically  significant  to  include 
results  of  HIV  serologic  testing: 

Recommendation  7:  Physicians  should  counsel 
patients  before  tests  for  HIV  to  educate  them  about  effective 
behaviors  to  avoid  the  risk  of  AIDS  for  themselves  and 
others-.  In  public  screening  programs,  counseling  may  be 
done  in  whatever  form  is  appropriate  given  the  resources 
and  personnel  available-as  long  as  effective-counseling-is 
provided-. 

Recommendation  8:  Physicians  should  counsel 
their  patients  who  are  found  to  be  seropositive  regarding 
(a)  responsible  behavior  to  prevent  the  spread  of  the 
disease,  (b)  strategies  for  health  protection  with  a 
compromised-  immune  system,  and  (c)  the  necessity  of 
alerting  sexual  contacts  from  the  past,  5-10  years  and 
present,  regarding  their  possible  infection  by  the  AIDS 
virus.  Long-term  emotional  support  should  be  provided 
or  arranged  for  seropositive  individuals.  Model 
confidentiality  laws  must  be  drafted  which  can  be  adopted 
at  all-levels  of  government  to  encourage  as  much 


Supplement  56  VOL  152  March  2000  J La  State  Med  Soc 


uniformity  as  possible  in  protecting  the  identity  of  AIDS 
patients  and  carriers,  except  where  the  public  health 
requires  otherwis-e: 

Recommendation  Sb-Public  funding  must  be 
provided  in  an  amount  sufficient  (a)  to  promptly  and 
efficiently  counsel  and  test  for  AIDS,  (b)  to  conduct  the 
research  necessary  to  find  a cure  and  develop  an  effective 
vaccine,  (c)  to  perform  studies  to  evaluate  the  efficiency 
of  counseling  and  education  programs  on  changing 
behavior,  and  (d)  to  assist  in  the  care  of  AIDS  patients 
who  cannot  afford  proper  care  or  who  cannot  find 
appropriate  facilities  for  treatment  and  care. 

Recommendation  10:  Specific  statutes  must  be 
drafted  which,  while  protecting  to  the  greatest  extent 
possible  the  confidentiality  of  patient  information  (a) 
provide  a method  for  warning  unsuspecting  sexual 
partners,  (b)  protect  physicians  from  liability  for  failure 
to  warn  the  unsuspecting  third  party  but,  (c)  establish 
clear  standards  for  when  a physician  should  inform  the 
public  health  authorities,  and  (d)  provide  clear  guidelines 
for  public  health  authorities  who  need  to  trace  the 
unsuspecting  sexual  partners  of  the  infected  person.  (R41- 
89) 

35.96  LSMS  Role  in  Allied  Health  Education  and 
Accreditation:  The  LSMS  believes  that-prior  to  a medical 
organization's  support  and/or  endorsement  of  any 
legislative  proposal  advocating  expansion  of -an-  allied 
health  professional's-scope  of  practice  of  the  registration, 
certification  or  licensure  of  new  allied  health  professionals, 
it -is  strongly  recommended -that  the  LSMS  Council  on 
Legislation  and  Office  of  Governmental  Affairs  be 
consulted  as  to  the  background,  impact-and  possible  legal 
implications  of  a proposal  before  such  action  is 
undertaken  recommends  that  the  Council  on  Legislation  and 
Department  of  Governmental  Affairs  be  consulted  by  other 
medical  organizations  before  those  organizations  support  or 
endorse  any  legislative  proposal  advocating  expansion  of  any 
allied  health  group's  scope  of  practice.  (R27-89) 

125.98  Generic  Substitution  by  Pharmacists:  The  LSMS 
opposes  the  practice  of  generic  substitution  of  drugs  by  a 
pharmacist  except  where  the  substitution  has  been  authorized 
by  the  prescribing  physician , the  reduction  of  sendees,  and 
the  reduction  in  quality  of  the  drugs  prescribed  in  order 
to  meet  political  promises.  The  LSMS  is  also  opposed  to 
such  reductions  while  increasing  the  administrative  costs 
erif  the  Medicaid  program.  The  LSMS  opposes  anv 
legislation  which  would  allow  a pharmacist  to  prescribe 
any  drugs  which  now  require  a prescription.  (R41-79) 

135.94  Development  of  Infectious  Medical  Waste 
Disposal  Regulations:  The  LSMS  resolves  to  work  with 
the  Department  of  Environmental  Quality  and  other 
interested  organizations  to  write  regulations  with 


appropriate  definition  of  infectious  waste  and  practical 
regulation  of  the  management  of  such  waste. 

The  LSMS  opposes  Louisiana  participation  in  a 
federal  demonstration  project  for  regulation  of  infectious 
waste  management,  pursuant  to  the  federal  Medical 
Waste  Tracking  Act  of  1988  (MWTA).(R30-89) 

170.99  Sex  Education  in  the  Schools:  The  LSMS  supports 
age  appropriate  sex  education  in  schools,  an  amendment  to 
RS  17:281  (A)  (1)  changing  "provided  that  no  such 
ins-truetion  shall  be  offered  in  kindergarten  or  in  grades 
one  though  six"  to  "provided  that  no  such  instruction  shall 
be  offered  in  kindergarten  or  in  grades  one  through  three." 
(R22-89) 

330.94  Restructuring  of  Medicare  Program:  The  LSMS 
supports  in  principle  the  concept  of  a total  restructuring 
of  Medicare,  such  as  proposed  in  H.R.  4455  introduced  in 
the-seeond  session  of  the  100th  Congress,  to  establish  a 
new  program  for  the  health  care  needs  of  the  elderly.  (R17- 
89) 

385.96  Payment  of  Claims  on  Health  and  Accident 
Policies:  The  LSMS  supports  state  legislation  to  amend 
and-darify  RS  22:657  in  such  a way  that  it  requires  the 
requiring  insurers  to  make  payments  to  physicians, 
hospitals  and  other  health  care  providers,  as  well  as  to 
the  patients  (insured)  in  accordance  with  laws  related  to 
assignment  of  benefits  within  30  days  of  receiving  proof 
of  claim,  or  to  be  subject  to  penalty  of  double  the  amount 
of  benefits  due  under  the  terms  of  the  policy  or  contract, 
together  with  court  approved  attorney  fees.  (R52-89) 

440.92  Funding  for  a Louisiana  Poison  Control  Center: 
The  LSMS  requests  endorses  funding  by  the  governor  for 
a poison  control  center  within  the  state  or  contract  with  a 
regional  national  center  which  allows  access  by  hospitals, 
physicians  and  parents.  (R68-89) 

475.98  Postoperative  Care:  The  LSMS  believes  that  the 
surgeon  performing  the  surgery,  or  another  MD  with 
appropriate  skills,  should  continue  to  provide  the  surgical 
postoperative  care.  (R3-89) 

490.96  "No  Smoking"  in  Health  Facilities:  The  LSMS 
endorses  and  supports  the  statement  that  there  shall  be 
no  cigarette  machines  in  any  health  facility  in  Louisiana 
and  encourages  "no  smoking"  signs  to  shall  be  installed  in 
all  health  facilities  and  physicians'  offices  of  the  state.  (R20- 
89) 

and  be  it  further 

RESOLVED,  that  the  following  policies  be  referred  to  the 
Board  of  Governors  for  legal  review: 


Supplement  57  VOL  152  March  2000  J La  State  Med  Soc 


98.98  Handling  of  Deceased  Physicians'  Medical 
Records 

96.96  Medical  Record  Privacy 

99.99  Third  Party  Requests  for  Patient  Information 
435.91  Guidelines  for  Malpractice  Case  Review  by 

Physicians 

(strikeouts  used  for  deletions,  italics  for  additions 

RESOLUTION  102 

Adopted  - 10/22/99 

SUBJECT:  LSMS  Continuing  Medical  Education  Award 
INTRODUCED  BY:  Committee  on  Continuing  Medical 
Education  Accreditation 

RESOLVED,  that  I.  Ricardo  Martinez,  Jr.,  M.D.,  Ph.D.  be 
the  recipient  of  the  1999  LSMS  Continuing  Medical 
Education  Award. 

RESOLUTION  103 

Adopted  10/22/99 

SUBJECT:  Medicine  and  Religion  Week 
INTRODUCED  BY:  Committee  on  Public  Relations 

RESOLVED,  that  in  recognition  of  the  need  for  divine 
guidance  of  all  who  serve  in  the  healthcare  field,  the  week 
of  October  15-21,  2000,  be  designated  as  Medicine  and 
Religion  Week.  Component  medical  societies  are  strongly 
urged  to  observe  this  special  period  through  the 
sponsorship  of  and  participation  in  special  programs  and 
services  in  houses  of  worship,  hospitals  and  other 
institutions  in  order  to  call  attention  to  the  emotional  and 
spiritual  requirements  of  patients  and  the  need  for  giving 
guidance  to  our  actions  and  judgments. 

RESOLUTION  104 

Adopted  as  amended  10/22/99 

SUBJECT:  AMA  Delegation  Reimbursement  Guidelines 
INTRODUCED  BY:  AMA  Delegation  Board  of  Governors 

RESOLVED,  the  LSMS  adopt  the  following  policy 
regarding  reimbursement  of  travel  expenses  for  the  AMA 
Official  Family: 

1.  Coach  airfare  - members  of  the  delegation  will  be 
reimbursed  the  actual  cost  of  round  trip  airfare  from  their 
point  of  origin  to  the  meeting  up  to  the  benchmark  of  the 
21-day  advance  purchase  cost. 

2.  Ground  transportation  - Ground  transportation  will 
include  airport  to  hotel,  hotel  to  airport  plus  any  airport 
parking  charges.  In  lieu  of  parking,  taxi  fare  from  home 
to  airport,  roundtrip,  is  acceptable. 

3.  Lodging  - members  of  the  delegation  will  be 
reimbursed  the  lowest  price  convention  room  rate  as 
publicized  on  the  AMA  registration  form,  plus  applicable 
taxes,  for  days  actually  spent  at  the  meeting,  with  a 
maximum  of  six  days  for  the  annual  meeting  and  five 


days  for  the  interim  meeting. 

4.  Other  expenses  - members  of  the  delegation  will  be 
reimbursed  up  to  a maximum  allowable  amount  per  day 
for  eligible  expenses  determined  by  the  delegation  and 
published  under  REIMBURSEMENT  FOR  MEETING 
EXPENSES  in  the  Delegation  Policy  and  Procedure 
Manual.  The  AMA  delegation  shall  annually  fix  the 
maximum  amount  of  the  reimbursement  from  the  funds 
allocated  to  the  delegation  in  the  LSMS  annual  budget, 
and  be  it  further 

RESOLVED,  that  any  former  AMA  President  from 
Louisiana  may  be  included  as  a member  of  the  LSMS 
Official  Family  to  the  AMA  in  attending  official  meetings 
of  the  AMA  House  of  Delegates  if  approved  by  the  Board 
of  Governors. 

RESOLUTION  105 

Adopted  as  amended  10/22/99 
SUBJECT:  Medicare  Fraud  Analysis 
INTRODUCED  BY:  Board  of  Governors 

RESOLVED,  that  the  LSMS  request  that  the  AMA  study 
and  report  with  a detailed  settlement  analysis  of  the  extent 
of  Medicare  fraud  and  abuse:  (a)  in  total,  (b)  by  physicians 
(differentiating  inadvertent  coding  errors  or  inadequate 
documentation  from  true  fraud),  and  (c)  all  other  health 
care  providers,  and  be  it  further 

RESOLVED,  that  the  LSMS  request  that  the  AMA  study 
and  report  on  what  elements  comprise  the  government's 
statistical  estimate  of  Medicare  fraud  or  abuse  involving 
10%  of  "all  expenditures,"  and  provide  us  with  assurances 
that  the  government  is  not  including  in  that  "estimate" 
the  government's  other  findings  of  wrong-doing,  which 
does  not  include  providers,  and  be  it  further 

RESOLVED,  that  the  LSMS  request  that  the  AMA  study 
and  report  on  what  elements  comprise  the  governments 
actual  settlements  of  Medicare  fraud  or  abuse,  and 
discourage  the  governments  policy  of  reporting 
"estimates"  of  Medicare  fraud  or  abuse,  and  be  it  further 

RESOLVED,  that  the  LSMS  AMA  delegation  submit  a 
resolution  to  the  AMA  interim  meeting  in  December  to 
achieve  these  goals. 

RESOLUTION  106 

Adopted  as  amended  10/22/99 

SUBJECT:  Persecution  by  the  Department  of  Justice 
INTRODUCED  BY:  Board  of  Governors 

RESOLVED,  that  the  LSMS  request  that  our  AMA 
consider  joining  with  other  health  care  professional 
organizations  in  legal  or  legislative  actions  to  cause  the 


Supplement  58  VOL  152  March  2000  J La  State  Med  Soc 


government  to  cease  and  desist  from  the  use  of  inflated 
accusations  of  fraud  and  abuse  by  health  care  providers, 
and  be  it  further 

RESOLVED,  that  the  LSMS  AMA  delegation  submit  a 
resolution  to  the  AMA  interim  meeting  in  December  to 
achieve  these  goals. 

RESOLUTION  107 

Withdrawn  10/22/99 
SUBJECT:  Medicare  Fraud 

INTRODUCED  BY:  Committee  on  Physician /Patient 
Advocacy 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
request  that  our  American  Medical  Association  study  and 
report  to  the  AMA  House  of  Delegates  on  the  extent  of 
fraud  and  abuse  actually  committed  by  physicians,  in 
contrast  to  inadvertent  coding  errors  or  inadequate 
documentation,  and  as  contrasted  to  proven  fraud  and 
abuse  by  other  health  care  providers,  and  be  it  further 

RESOLVED,  that  our  AMA  study  and  report  to  the  AMA 
House  of  Delegates  on  the  breakdown  by  provider  group 
of  the  government's  estimated  10%  of  all  medical 
expenditures  that  is  cited  as  attributed  to  fraud  or  abuse, 
and  whether  that  estimate  includes,  among  others,  the 
following  governmental  public  allegations: 

a)  overpayment  to  Medicare  HMOs  based  on  their 
expenditures  over  past  years, 

b)  $1  million/  day  ($365  million /year)  "wasted"  by  the 
Department  of  Veteran's  Affairs, 

c)  improper  and  illegal  delays  in  reimbursement  to 
providers  by  managed  care  organizations  for  their  use  of 
the  economic  "float," 

d)  improper  misuse  of  funds  and  misconduct  by 
Medicare  fraud  private  "contractors," 

e)  inexplicable  differences  in  the  premiums  Medicare 
patients  are  charged  for  identical  Medigap  policy  benefits, 

f)  improper  denials  of  benefits  to  patients  to  maximize 
profits  by  insurers,  and  other  examples  of  fraud  and  abuse. 

RESOLUTION  108 

Adopted  as  amended  10/22/99 

SUBJECT:  AMA  Policy  on  Release  of  Medical  Records 
INTRODUCED  BY:  Board  of  Governors 

RESOLVED,  that  the  LSMS  request  that  the  AMA  educate 
physicians  to  help  them  understand  their  legal,  as  well  as 
ethical  responsibility  to  appropriately  guard  patient 
confidentiality,  which  may  necessitate  withholding 
confidential  elements  of  a patient's  medical  record,  and 
be  it  further 


RESOLVED,  that  the  LSMS  request  that  the  AMA 
continue  efforts  to  assure  the  necessary  legal  protections 
for  physicians,  who  strive  to  protect  the  confidences  of 
their  patients. 

RESOLVED,  that  the  LSMS  AMA  delegation  submit  a 
resolution  to  the  interim  AMA  meeting. 

RESOLUTION  109 

Substitute  resolution  adopted  10/22/99 

SUBJECT:  Physician  Office  Medical  Records  Release 

Guidelines 

INTRODUCED  BY:  Michael  S.  Ellis,  MD,  Immediate 
Past  President 

RESOLVED,  that  LSMS  Board  of  Governors  study  the 
issues  related  to  the  release  of  medical  records  and 
develop  an  appropriate  mechanism  to  educate  our 
member  physicians  on  how  to  legally  and  ethically  release 
their  patient's  medical  records. 

RESOLUTION  110 

Adopted  10/22/99 

SUBJECT:  Formation  of  LSMS  "Rural  Caucus" 
INTRODUCED  BY:  East  and  West  Feliciana  Medical 
Society 

RESOLVED,  the  LSMS  House  of  Delegates  formally 
recognize  the  formation  of  a LSMS  "Rural  Caucus"  for 
parishes  with  6 or  less  delegates. 

RESOLUTION  111 

Adopted  10/22/99 

SUBJECT:  Annual  Physician  Award  For  Community 
Service 

INTRODUCED  BY:  Shreveport  Medical  Society 

RESOLVED,  that  the  LSMS  establish  an  appropriate 
award  and  recognition  process  for  selecting  and 
recognizing  a physician  or  physicians  at  the  Annual 
Meeting  each  year  for  their  achievements  and  community 
service. 

RESOLUTION  112 

Adopted  10/22/99 

SUBJECT:  Nomination  for  the  LSMS  Hall  of  Fame 
INTRODUCED  BY:  Committee  on  Hall  of  Fame 

RESOLVED,  that  in  recognition  of  his  valuable  leadership 
and  dedicated  service  in  numerous  elected  and  appointed 
positions  of  responsibility  in  the  LSMS,  Elmo  J.  LaBorde, 
MD,  of  Lafayette,  be  elected  to  the  Hall  of  Fame  of  the 
Louisiana  State  Medical  Society. 


Supplement  59  VOL  152  March  2000  J La  State  Med  Soc 


RESOLUTION  113 

Adopted  10/22/99 

SUBJECT:  Physicians'  Health  Committee 
INTRODUCED  BY:  Physicians'  Health  Committee 

RESOLVED,  that  the  Physicians'  Health  Committee  be 
removed  as  a standing  committee  of  the  Louisiana  State 
Medical  Society. 

RESOLUTION  114 

Defeated  10/22/99 

SUBJECT:  Short  Descriptive  Statements  for  All  LSMS 
Resolutions 

INTRODUCED  BY:  Marcus  L.  Pittman,  III,  M.D., 
Councilor,  District  10 

RESOLVED,  that,  to  insure  that  the  purpose  and  / or  intent 
of  RESOLUTIONS  are  not  forgotten  or  misinterpreted, 
all  future  LSMS  RESOLUTIONS  should  contain  a short 
descriptive  statement  (e.g.  "in  order  that...,"  "to  insure 
that...,"  etc.). 

RESOLUTION  115 

Adopted  as  amended  10/22/99 

SUBJECT:  Component  Society  Meetings  with  Area 

Legislators 

INTRODUCED  BY:  Eduardo  Rodriguez,  MD, 

Delegate,  Orleans  Parish  Medical  Society 

RESOLVED,  that  the  LSMS  promote  regular  dialogue 
between  individual  legislators  and  LSMS  members  living 
in  the  legislators'  districts,  and  be  it  further 

RESOLVED,  in  order  to  promote  dialogue  between 
individual  legislators  and  LSMS  members  living  in  their 
districts,  the  LSMS  encourage  component  societies  to  have 
meetings  at  least  annually  with  individual  legislators  and 
LSMS  members  living  in  those  districts,  and  be  it  further 

RESOLVED,  that  when  requested  by  component 
societies,  the  LSMS  will  assist  in  coordinating  the  annual 
meetings  with  individual  legislators,  including 
scheduling,  participating  in  and/or  providing 
background  information  for  the  meetings. 

RESOLUTION  116 

Defeated  10/22/99 

SUBJECT:  Annual  LSMS  Membership  Meeting/ 
Continuing  Medical  Education  Seminar 
INTRODUCED  BY:  Floyd  Buras,  MD,  Delegate, 

Orleans  Parish  Medical  Society 

RESOLVED,  that  the  LSMS  evaluate,  and  if  possible 
implement,  before  the  next  House  of  Delegates'  meeting. 


an  annual  membership  meeting,  combined  with  an 
educational  meeting  offering  CME  credits,  and  be  it 
further 

RESOLVED,  that  the  LSMS  evaluate,  and  if  possible 
implement  holding  an  Annual  Membership  meeting/ 
CME  program  in  a resort  destination  which  would 
provide  adequate  facilities  for  the  meeting,  social  events, 
and  family/ sporting  activities,  and  be  it  further 

RESOLVED,  that  the  LSMS  assess  registration  fees  and 
seminar  fees  and  solicit  exhibitors  and/or  sponsors 
adequate  to  cover  the  costs  of  such  an  annual  membership 
meeting/ CME  program,  and  be  it  further 

RESOLVED,  that  the  LSMS  send  targeted 
communications  about  this  event  to  young  physician 
members  and  prospective  members. 

RESOLUTION  117 

Substitute  resolution  adopted  10/22/99 

SUBJECT:  Assistance  to  Members  in  Adjudicating 

Health  Insurance  Claims 

INTRODUCED  BY:  Floyd  Buras,  MD,  Delegate, 

Orleans  Parish  Medical  Society 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
Managed  Care  Liaison  Committee  evaluate  how  best  to 
assist  LSMS  members  in  the  adjudication  of  health 
insurance  and  managed  care  claims. 

RESOLUTION  118 

Substitute  resolution  adopted  10/22/99 
SUBJECT:  Emergency  Room  Physician  Qualifications 
INTRODUCED  BY:  Kenneth  Parks,  MD,  Alternate 
Delegate;  St.  Landry  Parish  Medical  Society 

RESOLVED,  the  Louisiana  State  Medical  Society  rescind 
its  policy  130.90,  Recommended  Education,  Training,  and 
Experience  for  Emergency  Medicine  Privileges. 

RESOLUTION  119 

SUBJECT:  Operations  and  Functions  of  the  House  of 
Delegates 

INTRODUCED  BY:  Ad  Hoc  Committee  on  Operation 
and  Functioning  of  the  HOD 

Substitute  resolves  1-4  adopted  as  amended  10/22/99 

RESOLVED,  that  all  resident  members  must  be  a member 
of  the  Resident  Section  and  a member  of  the  component 
medical  society  of  their  choice,  and  be  it  further 

RESOLVED,  that  the  LSMS  House  of  Delegates  Resident 


Supplement  60  VOL  152  March  2000  J La  State  Med  Soc 


Section  be  composed  of  one  delegate  and  one  alternate 
delegate  from  each  ACGME  accredited  training  institution 
with  greater  than  100  residents.  Component  societies  may 
have  one  additional  delegate  and  one  alternate  delegate 
for  each  200  residents  members  or  fraction  thereof  in  their 
societies.  These  additional  delegates  must  be  residents, 
and  be  it  further 

RESOLVED,  that  all  student  members  must  be  a member 
of  the  Medical  Student  Section  and  a member  of  the 
component  medical  society  of  their  choice,  and  be  it 
further 

RESOLVED,  that  the  LSMS  House  of  Delegates  Medical 
Student  Section  be  composed  of  one  delegate  and  one 
alternate-delegate  from  each  Louisiana  LCME  accredited 
medical  school.  Component  societies  may  have  one 
additional  delegate  and  one  alternate  delegate  for  each 
200  medical  student  members  or  fraction  thereof  in  their 
societies.  These  additional  delegates  must  be  medical 
students,  and  be  it  further 

Resolve  5 referred  to  the  Specialty  Society  Committee  10/22/99 
RESOLVED,  that  the  LSMS  will  allow  LSMS  approved 
board  certified  specialty  societies  that  have  a state  chapter 
in  Louisiana  to  send  a delegate  to  the  House  of  Delegates. 
The  representative  that  is  chosen  as  the  specialty  delegate 
must  be  a member  of  the  LSMS,  and  be  it  further 

Resolve  6 adopted  10/22/99 

RESOLVED,  that  the  LSMS  include  in  the  HOD 
Handbook  a brief  summary  of  each  elected  office 
including  the  duties  and  approximate  time  required  to 
fulfill  that  position,  and  be  it  further 

Resolve  7 adopted  as  amended  10/22/99 
RESOLVED,  that  an  election  packet,  which  would  include 
a listing  of  all  proposed  candidates  and  their 
qualifications,  be  developed  for  distribution  during 
registration  for  the  House  of  Delegates,  and  be  it  further 

Resolve  8 defeated  10/22/99 

RESOLVED,  that  district  councilors  will  be  elected  by 
their  respective  districts  before  the  convening  of  the  House 
of  Delegates,  and  those  elected  councilors  will  be 
announced  on  the  floor  of  the  House  of  Delegates,  and  be 
it  further 

Resolve  9 adopted  as  amended  10/22/99 
RESOLVED,  that  the  Districts  be  redistricted  every  10 
years,  starting  in  2001,  using  the  recommendation  of  the 
Board  of  Councilors  to  determine  the  makeup  of  the 
districts,  and  be  it  further 


Resolve  10  adopted  10/22/99 

RESOLVED,  that  the  methods  of  increasing  participation 
by  other  medical  organizations  in  the  House  of  Delegates 
as  Official  Observers  be  referred  to  the  Board  of  Governors. 

RESOLUTION  120 

Adopted  as  amended  10/22/99 

SUBJECT:  Change  in  LSMS  policy  315.97  on  Medical 

Records 

INTRODUCED  BY:  Michael  S.  Ellis,  MD,  Immediate 
Past  President 

RESOLVED,  that  current  LSMS  policy  on  the  retention  of 
medical  records  be  as  follows: 

Retention  of  Medical  Records:  In  conformity  with 
Louisiana  Revised  Statue  40:1299.96  A.  (3)(a)  Medical  and 
dental  records  shall  be  retained  by  a physician  or  dentist 
in  the  original,  microfilmed,  or  similarly  reproduced  form 
for  a minimum  period  of  six  years  from  the  date  a patient 
is  last  treated  by  a physician  or  dentist,  (b)  Graphic  matter, 
images,  X-ray  films,  and  like  matter  that  were  necessary 
to  produce  a diagnostic  or  therapeutic  report  shall  be 
retained,  preserved  and  properly  stored  by  a physician  or 
dentist  in  the  original,  microfilmed  or  similarly  reproduced 
form  for  a minimum  period  of  three  years  from  the  date  a 
patient  is  last  treated  by  the  physician  or  dentist.  Such 
graphic  matter,  images,  X-ray  film,  and  like  matter  shall 
be  retained  for  a longer  period  when  requested  in  writing 
by  the  patient. 

RESOLUTION  121 

Adopted  10/22/99 

SUBJECT:  Hall  of  Fame  Nominees 

INTRODUCED  BY:  Committee  on  Hall  of  Fame 

RESOLVED,  that  the  nominees  to  the  Louisiana  State 
Medical  Society  Hall  of  Fame  be  limited  to  two  with  any 
combination  of  living  or  deceased  members. 

RESOLUTION  201 

Adopted  as  amended  10/23/99 

SUBJECT:  Sunset  Mechanism  for  House  of  Delegates 
Generated  Legislative  Initiative 
INTRODUCED  BY:  Council  on  Legislation 

RESOLVED,  that  the  legislative  initiatives  of  the  House 
of  Delegates  be  abandoned  on  the  following  matters,  but 
positions  enunciated  will  remain  LSMS  policy: 

1993:  203 

1996:  206,  210,  212,  225 
1997:  202,  205,  208,  215,  217,  223,  226,  227 
1998:  202,  203,  205,  206,  210,  211,  212,  213,  223 
and  be  it  further 


Supplement  61  VOL  152  March  2000  J La  State  Med  Soc 


RESOLVED,  that  the  following  legislative  initiatives  of 
the  House  of  Delegates  be  renewed  for  the  1999  legislative 
session. 

1995:  203 

1996:  205,  208,  211 

1997:  203,  210,  225 

1998:  207,  214,  215,  216,  219,  221 

RESOLUTION  202 

Adopted  as  amended  10/23/99 
SUBJECT:  Medicaid  Reimbursement 
INTRODUCED  BY:  Committee  on  Pediatric  Health 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
communicate  with  DHH  in  an  attempt  to  improve 
Medicaid  reimbursement  for  physicians. 

RESOLUTION  203 

Adopted  as  amended  10/22/99 
SUBJECT:  Youth  Violence  Prevention 
INTRODUCED  BY:  Committee  on  Pediatric  Health 

RESOLVED,  that  the  Louisiana  State  Medical  Society  refer 
to  the  Committee  on  Pediatric  Health  for  the  purposes 
of: 

1)  evaluating  the  "Boston  City  Hospital  Violence 
Prevention  Program"  and  such  programs  in  other  states 
to  determine  their  possible  implementation  in  Louisiana; 

2)  working  with  state  and  local  agencies  (Department 
of  Education,  law  enforcement,  church  and  civic  groups, 
etc.)  to  support  programs  to  address  youth  violence. 

RESOLUTION  204 

Adopted  as  amended  10/23/99 
SUBJECT:  Prescriptive  Contraceptive  Equity 
INTRODUCED  BY:  Committee  on  Maternal  and 
Perinatal  Health 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
support  regulatory  and  legislative  efforts  to  include 
prescriptive  contraceptive  coverage  in  the  formulary  of 
health  plans  that  offer  other  prescriptive  coverage  to  their 
members. 

RESOLUTION  205 

Amended  resolution  adopted  10/23/99 
SUBJECT:  Insurance  Coverage 
INTRODUCED  BY:  Committee  on  Maternal  and 
Perinatal  Health 

RESOLVED,  that  the  LSMS  support  legislation  or 
regulations  to  require  that  health  insurance  plans  and 
managed  care  plans  make  clearly  known  to  patients  the 
extent  of  coverage  available  under  their  policies. 


RESOLUTION  206 

Substitute  resolution  adopted  10/23/99 
SUBJECT:  Online  Prescriptive  Drug  Services  and 
Promotion  of  Unconventional  Treatment  Therapies 
INTRODUCED  BY:  Shreveport  Medical  Society 

RESOLVED,  that  the  LSMS  adopt  as  policy  opposition 
to  the  online  prescribing  of  medications  and  treatments 
for  patients  in  Louisiana  by  physicians  who  lack  a 
relationship  with  the  patient,  and  to  seek  means  to  protect 
and  enhance  legitimate  electronic  prescribing  and 
dispensing  practice,  and  be  it  further 

RESOLVED,  that  the  LSMS  request  that  the  Louisiana 
State  Board  of  Medical  Examiners  create  a regulation  or 
issue  an  opinion  to  establish  that  Internet  online 
prescriptions  are  legal  in  Louisiana  only  if  the  physician 
and  the  patient  have  an  ongoing  relationship,  and  be  it 
further, 

RESOLVED,  that  the  LSMS  support  the  Louisiana  State 
Board  of  Medical  Examiners,  the  Louisiana  Department 
of  Health  and  Hospitals,  and  the  Louisiana  State  Board 
of  Pharmacy  in  establishing  standards  for  evaluating 
Internet  prescribing  of  treatment  therapies  that  may  be 
in  violation  of  the  Louisiana  Medical  Practice  Act,  the 
Louisiana  Pharmacy  Act,  and  existing  laws  and 
regulations,  and  develop  if  necessary  a mechanism  to 
enforce  these  standards,  and  be  it  further 

RESOLVED,  that  the  LSMS  support  the  AMA 
recommendations  on  Internet  prescribing  as: 

1.  That  our  AMA  develop  principles  describing 
appropriate  use  of  the  Internet  in  prescribing  medications; 

2.  That  our  AMA  support  the  use  of  the  Internet  as  a 
mechanism  to  prescribe  medications  with  appropriate 
safeguards  to  ensure  that  the  standards  for  high  quality 
medical  care  are  fulfilled; 

3.  That  our  AMA  work  with  state  medical  societies  in 
urging  state  medical  boards  to  ensure  high  quality  medical 
care  by  investigating  and,  when  appropriate,  taking 
necessary  action  against  physicians  who  fail  to  meet  the 
local  standards  of  medical  care  when  issuing  prescriptions 
through  Internet  web  sites  that  dispense  prescription 
medications; 

4.  That  our  AMA  work  with  the  Federation  of  State 
Medical  Boards  and  others  in  endorsing  or  developing 
model  state  legislation  to  establish  limitations  on  Internet 
prescribing; 

5.  That  our  AMA  continue  to  work  with  the  National 
Association  of  Boards  of  Pharmacy  and  support  their 
"Verified  Internet  Pharmacy  Practice  Sites"  program  so 
that  physicians  and  patients  can  easily  identify  legitimate 
Internet  pharmacy  practice  sites; 


Supplement  62  VOL  152  March  2000  J La  State  Med  Soc 


6.  That  our  AMA  work  with  federal  and  state  regulatory 
bodies  to  close  down  Internet  web  sites  of  companies  that 
are  illegally  promoting  and  distribution  (selling) 
prescription  drug  products  in  the  United  States;  and 

7.  That  our  AMA  keep  pace  with  changes  in  technology 
by  continually  updating  standards  of  practice  on  the 
Internet. 

RESOLUTION  207 

Amended  resolution  adopted  10/23/99 

SUBJECT:  Funding  for  the  Physicians'  Health  Foundation 

of  Louisiana 

INTRODUCED  BY:  Physicians'  Health  Committee 

RESOLVED,  that  the  Louisiana  State  Medical  Society  seek 
and/or  support  legislation  in  the  2000  fiscal  session  of 
the  Louisiana  legislature,  establishing  the  addition  of  a 
fee  of  up  to  twenty-five  (25)  dollars  per  year,  to  the 
licensing  fee  currently  assessed  by  the  Louisiana  State 
Board  of  Medical  Examiners  to  be  directed  to  and  for  the 
benefit  of  the  Physicians'  Health  Foundation  of  Louisiana, 
which  will  then  be  used  to  assist  physicians  in  the  state  of 
Louisiana  participating  in  the  Physicians'  Health 
Program. 

RESOLUTION  208 

Withdrawn 

SUBJECT:  Consent  for  Organ  Donation  Through  Non- 
Use  of  Helmet  While  Driver  or  Passenger  on  a Motorcycle 
INTRODUCED  BY:  Marcus  L.  Pittman,  III,  M.D., 
Councilor,  District  10 

RESOLVED,  that,  in  order  to  benefit  the  public  from  lost 
health  care  costs  resulting  from  the  treatment  of 
motorcycle  accident  victims  with  head  injuries,  the  LSMS 
seek  and/ or  support  legislation  that  would  consider  the 
absence  of  wearing  a helmet  in  a motorcycle  accident  to 
constitute  consent  for  organ  donation,  in  the  event  of 
death  or  brain  death  in  a motorcycle  accident  while  not 
wearing  a helmet. 

RESOLUTION  209 

Defeated  10/23/99 

SUBJECT:  Active  Hospital  Medical  Staff  Privileges 
Constitute  Automatic  Acceptance  as  a Provider 
INTRODUCED  BY:  Marcus  L.  Pittman,  m,  M.D., 
Councilor,  District  10 

RESOLVED,  that,  in  order  to  lessen  the  duplication  of 
paperwork  and  to  minimize  the  expense  of  credentialing, 
the  Louisiana  State  Medical  Society  seek  and/or  support 
legislation  requiring  insurance  companies  and  third  party 
carriers  that  contract  with  a hospital  to  automatically 
accept  all  active  members  of  that  hospital's  medical  staff 
as  providers  without  further  application  process. 


RESOLUTION  210 

Defeated  10/23/99 

SUBJECT:  Requirement  that  Patients  Give  Specific 
Consent  for  the  Release  of  Medical  Information 
INTRODUCED  BY:  Marcus  L.  Pittman,  IH,  M.D., 
Councilor,  District  10 

RESOLVED,  that,  in  order  to  stop  unintended  disclosure 
of  what  should  be  restricted  patient  medical  records,  the 
Louisiana  State  Medical  Society  seek  and/or  support 
legislation  that  would  require  release  forms  for  patient 
medical  records  to  be  specific  and  include  (at  a minimum): 
a starting  period,  an  ending  period  (not  exceeding  past 
the  date  of  the  signed  release),  specific  conditions  / events  / 
records  requested,  and  the  signature  of  the  patient  or 
responsible  party. 

RESOLUTION  211 

Substitute  resolution  adopted  10/22/99 
SUBJECT:  Hospital  Disclosure  and  Quality 
Improvement 

INTRODUCED  BY:  William  St.  J.  LaCorte,  M.D., 
Delegate,  Orleans  Parish  Medical  Society 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
communicate  with  professional  organizations  that 
represent  other  health  care  professionals  and 
organizations,  such  as  nursing,  allied  health,  and 
hospitals,  to  determine  their  level  of  concern  as  to  whether 
hospitals  are  meeting  established  standards  of  patients 
care;  and  to  be  further 

RESOLVED,  that  the  LSMS  support  hospital  staffing 
sufficient  to  provide  full  patient  care  twenty-four  hours  a 
day,  seven  days  a week,  and  be  it  further 

RESOLVED,  that  the  LSMS  meet  with  the  Louisiana 
Hospital  Association  and  other  professional  associations 
representing  healthcare  professional  to  express  concerns 
over  the  level  of  staffing  of  some  hospitals,  and  be  it 
further 

RESOLVED,  that  the  LSMS  seek  and/ or  support  policy 
that  requires  hospitals  to  disclose  to  their  medical  staffs 
any  disciplinary  action  or  consent  decree  to  which  the 
hospital  has  been  subjected. 

RESOLUTION  212 

Amended  resolution  adopted  10/23/99 

SUBJECT:  Employer  Financial  Requirements  to  Offer  PPO 

Product  to  Employees 

INTRODUCED  BY:  Orleans  Parish  Medical  Society 

RESOLVED,  that  LSMS  seek  and/or  support  federal 
regulation  or  legislation  via  the  AMLA  delegation  which 


Supplement  63  VOL  152  March  2000  J La  State  Med  Soc 


would  require  employers  which  have  self-funded 
insurance  plans  and  which  are  offering  preferred  provider 
organization  plans  to  their  employees  to  maintain  three 
months'  of  claims  expenses  based  on  the  prior  year's 
experience  or  an  equivalent  nonrefundable  cash  guarantee 
in  escrow  with  the  Insurance  Department  for  the  timely 
payment  of  claims. 

RESOLUTION  213 

Adopted  10/23/99 

SUBJECT:  Adoption  of  RBRVS  for  Medicaid 
Reimbursement 

INTRODUCED  BY:  Orleans  Parish  Medical  Society 

RESOLVED,  that  the  Louisiana  State  Medical  Society  seek 
and  / or  support  Department  of  Health  and  Hospital  rule 
changes  that  would  allow  adoption  of  a Resource  Based  - 
Relative  Value  Scale  as  its  method  of  reimbursement  for 
Medicaid  services,  and  be  it  further 

RESOLVED,  that  should  legislation  be  required  from  the 
Louisiana  legislature  to  implement  adoption  of  a Resource 
Based  - Relative  Value  Scale  for  Medicaid  reimbursement, 
the  Louisiana  State  Medical  Society  would  seek  and/or 
support  such  legislation. 

RESOLUTION  214 

Amended  resolution  adopted  10/23/99 
SUBJECT:  Verification  of  Verbal  Orders 
INTRODUCED  BY:  F.  Brobson  Lutz,  Jr.,  M.D.,  Delegate, 
Orleans  Parish  Medical  Society 

RESOLVED,  that  the  Louisiana  State  Medical  Society, 
support  DHH  regulatory  changes  that  would  allow 
signatures,  without  date  or  time,  to  certify  a telephone  or 
verbal  order  as  authentic  for  hospital  or  nursing  home 
medical  records. 

RESOLUTION  215 

Adopted  10/23/99 

SUBJECT:  Reporting  of  Incapacitated  or  Unqualified 
Drivers 

INTRODUCED  BY:  Orleans  Parish  Medical  Society 

RESOLVED,  that  the  Louisiana  State  Medical  Society  seek 
and  / or  support  legislation,  similar  to  that  in  the  state  of 
Missouri,  that  ensures  total  confidentiality  and  immunity 
from  civil  liability  for  anyone  when  acting  in  good  faith 
be  added  to  the  current  state  law  regarding  the  reporting 
of  incapacitated  or  unqualified  drivers  in  Louisiana. 

RESOLUTION  216 

Withdrawn 

SUBJECT:  Proof  of  Timely  Filing 


INTRODUCED  BY:  Orleans  Parish  Medical  Society 

RESOLVED,  that  LSMS  seek  and/ or  support  regulations 
or  legislation  which  would  require  health  insurance 
companies  and  managed  care  entities  to  accept  either 
printouts  from  provider  systems  and/or  electronic 
responses  from  a clearing  house  which  verifies  that  there 
were  no  errors  as  proof  of  timely  submission. 

RESOLUTION  217 

Withdrawn 

SUBJECT:  Inappropriate  Denial  of  Medical  Claims 
INTRODUCED  BY:  Floyd  Buras,  MD,  Delegate, 

Orleans  Parish  Medical  Society 

RESOLVED,  that  the  LSMS  seek  and/or  support 
regulation  or  legislation  which  ensures  an  equal  burden 
of  proof  on  the  physician  and  the  health  insurance  entity 
or  managed  care  entity,  so  that  when  an  error  occurs  on  a 
submitted  claim,  the  party  responsible  for  the  error  has 
to  correct  the  error,  and  be  it  further 

RESOLVED,  that  the  LSMS  seek  and/or  support 
regulation  or  legislation  that  requires  the  Insurance 
Commissioner  to  be  the  sole  judge  of  the  responsible  party 
of  a disputed  medical  claims  error,  and  that  this 
determination  will  be  made  by  the  Insurance 
Commissioner  at  the  request  of  either  party. 

RESOLUTION  218 

Withdrawn 

SUBJECT:  Telephone  Numbers  for  Use  By  Patients  in 
Contacting  Health  Insurance  / Managed  Care  Entities 
INTRODUCED  BY:  Floyd  Buras,  MD,  Delegate, 

Orleans  Parish  Medical  Society 

RESOLVED,  that  the  LSMS  seek  and/or  support 
regulation  or  legislation  that  allows  a patient  access  to 
his/her  health  insurer,  or  health  insurance  information, 
using  any  published  phone  number  for  the  company, 
including,  but  not  limited  to  Patient  Relations,  Provider 
Relations,  or  Sales  and  Marketing. 

RESOLUTION  219 

Adopted  10//23/99 

SUBJECT:  Authorization  of  Treatment  Constitutes 

Primary  Responsibility  To  Pay 

INTRODUCED  BY:  Orleans  Parish  Medical  Society 

RESOLVED,  that  the  LSMS  seek  and/or  support 
legislation  or  regulation  establishing  that  any  managed 
care  entity  that  determines  the  medical  authorization  to 
provide  health  benefits  would  then  also  be  declared  the 
primary  payor,  thus  becoming  primarily  responsible  to 
provide  payment  for  those  benefits  that  it  authorized. 


Supplement  64  VOL  152  March  2000  J La  State  Med  Soc 


RESOLUTION  220 

Substitute  resolution  adopted  as  amended  10/23/99 
SUBJECT:  Medicare's  Responsibility  to  Reveal  Reasons 
for  Denial 

INTRODUCED  BY:  Delegate,  Orleans  Parish  Medical 
Society 

RESOLVED,  that  LSMS  seek  and/or  support  federal 
regulations  that  require  Medicare  to  reveal  the  reasons 
for  failure  to  pay,  and  publish  their  parameters  of 
reimbursement  so  that  the  patients  and  physicians  are 
better  informed  as  to  the  proper  manner  in  which  to  deal 
with  this  government  agency,  and  be  it  further 

RESOLVED,  that  the  LSMS  AMA  Delegation  introduce  a 
similar  resolution  requiring  Medicare  to  reveal  the  reasons 
for  failure  to  pay,  and  publish  their  parameters  of 
reimbursement  to  the  AMA  House  of  Delegates. 

RESOLUTION  221 

Substitute  resolution  adopted  as  amended  10/23/99 
SUBJECT:  Discoverability  and  Availability  of  Insurance 
Documents  Related  to  Reimbursement  and  Patient  Care 
INTRODUCED  BY:  Orleans  Parish  Medical  Society 

RESOLVED,  that  the  LSMS  seek  and/or  support 
regulation  and  / or  legislation  requiring  third  party  payors 
upon  request  to  disclose  to  physicians  utilization  review 
criteria  used  to  determine  patient  treatment  and 
reimbursement. 

RESOLUTION  222 

Referred  to  Managed  Care  Liaison  Committee 
SUBJECT:  Difference  Between  Printed  Co-Pay  Amount 
and  Actual  Co-Pay 

INTRODUCED  BY:  Floyd  A.  Buras,  Jr.,  M.D.,  Delegate, 
Orleans  Parish  Medical  Society 

RESOLVED,  that  the  LSMS  seek  and/or  support 
regulation  and/or  legislation  that  requires  that,  should 
the  insurance  card  supplied  to  a patient  by  their  insurance 
company  contain  errors  as  to  the  amount  of  benefit  or 
copay,  then  it  is  the  financial  responsibility  of  the 
insurance  company  to  make  up  the  difference  between 
what  is  printed  on  the  insurance  card  and  what  the 
insurance  company  later  says  it  should  have  been. 

RESOLUTION  223 

Referred  to  Managed  Care  Liaison  Committee  10/23/99 
SUBJECT:  Patient's  Responsibility  to  Pay  Full  Charges 
INTRODUCED  BY:  Floyd  Buras,  MD,  Delegate, 

Orleans  Parish  Medical  Society 


RESOLVED,  that  the  LSMS  seek  and/or  support 
legislation  and/or  regulation  to  require  that  when  the 
patient  refuses  to  pay  their  portion,  the  patient  is 
responsible  for  the  full  payment  and  any  discount  allowed 
by  the  insurance  company  is  no  longer  valid. 

RESOLUTION  224 

Withdrawn 

SUBJECT:  Removal  of  Responsibility  from  Physician  to 
Demonstrate  Efficacy  and  Cost-Effectiveness  of  HCFA  and 
JCAHO  Rules 

INTRODUCED  BY:  Floyd  Buras,  MD,  Delegate, 

Orleans  Parish  Medical  Society 

RESOLVED,  that  the  LSMS  seek  and/or  support 
regulation  and/or  legislation  that  removes  from 
practicing  physicians  the  responsibility  to  demonstrate 
the  efficacy  and  cost-effectiveness  of  HCFA  and  JCAHO 
rules  and  regulations. 

RESOLUTION  225 

Withdrawn 

SUBJECT:  Proof  of  Timely  Filing 
INTRODUCED  BY:  Orleans  Parish  Medical  Society 

RESOLVED,  that  the  LSMS  seek  and/or  support 
regulation  and/or  legislation  providing  that  once  the 
physician  has  sent  a request  for  a payment  into  the 
insurance  company,  the  insurance  company  must  provide 
immediate  proof  that  it  has  received  that  claim,  and  be  it 
further 

RESOLVED,  that  the  LSMS  seek  and/or  support 
legislation  and/or  regulation  such  that,  if  the  physician 
has  filed  a claim  in  a timely  manner,  the  insurance 
company  cannot  deny  payment  on  the  grounds  that  the 
claim  is  too  old  to  pay. 

RESOLUTION  226 

Referred  to  Board  of  Governors 

SUBJECT:  Collection  of  Local /Parish  Sales  Tax  for  Use 
and/ or  Administration  of  Drugs  in  Physicians' 

Practices 

INTRODUCED  BY:  Orleans  Parish  Medical  Society 

RESOLVED,  that  LSMS  support  and/ or  seek  regulation 
and/or  legislation  to  exempt  physician  practices  from 
paying  local  or  parish  sales  tax  for  the  use  and/or 
administration  of  drugs  in  their  offices,  and  which  does 
not  require  the  physician  to  collect  the  taxes  from  patients 
for  the  use  of  and/or  administration  of  drugs  in  their 
offices. 

RESOLVED,  that  the  LSMS  seek  and/or  support 


Supplement  65  VOL  152  March  2000  J La  State  Med  Soc 


regulations  or  legislation  to  exempt  physician  practices 
that  dispense  prescription  medications  from  sales  tax 
collection  in  their  offices. 

RESOLUTION  227 

Adopted  10/22/99 

SUBJECT:  Legislative  Priorities  and  Implementation 
INTRODUCED  BY:  Board  of  Governors 

RESOLVED,  the  Executive  Committee  of  the  Board  of 
Governors,  in  consultation  with  the  Council  on  Legislation 
and  the  Speakers,  prioritize  the  LSMS  state  legislative 
effort  on  an  ongoing,  as  needed,  basis  predicated  upon 
the  practical  and  political  realities  existing  at  the  time, 
and  be  it  further 

RESOLVED,  the  LSMS  recognize  that  the  Department  of 
Governmental  Affairs,  on  occasion,  may  exercise 
appropriate  legislative  discretion  within  the  LSMS  priority 
system  and,  in  accordance  with  existing  LSMS  policy, 
during  unpredictable  legislative  circumstances  calling  for 
immediate  action. 

RESOLUTION  228 

Resolution  adopted  as  amended  10/23/99 
SUBJECT:  Joint  Negotiations  by  Physicians  With 
Health  Insurance  Issuers 
INTRODUCED  BY:  Board  of  Governors  AMA 
Delegation 

RESOLVED,  that  the  LSMS  seek  and/or  support 
legislation  similar  to  Texas  legislation  which  authorizes 
joint  negotiations  by  physicians  with  health  insurance 
issuers  utilizing  the  state  action  doctrine  of  anti-trust 
exemption. 

RESOLUTION  301 

Adopted  10/22/99 

SUBJECT:  Osteoporosis  Prevention 
INTRODUCED  BY:  Committee  on  Chronic  Diseases 

RESOLVED,  the  Louisiana  State  Medical  Society 
disseminate  information  encouraging  primary  care 
physicians  to  take  advantage  of  bone  density  testing, 
when  indicated,  to  diagnose  osteoporosis  and  correct  it, 
and  be  it  further 

RESOLVED,  that  LSMS  encourage  primary  care 
physicians  to  communicate  with  their  patients  regarding 
prevention  and  treatment  of  osteoporosis. 

RESOLUTION  302 

Adopted  as  amended  10/23/99 
SUBJECT:  Childhood  Immunizations 


INTRODUCED  BY:  Committee  on  Maternal  and 
Perinatal  Health 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
strongly  endorses  the  continued  immunization  of  children 
as  recommended  by  the  medically-accepted  guidelines 
of  the  American  Academy  of  Pediatrics,  and/or  the 
Advisory  Committee  on  Immunization  Practices  and  be 
it  further 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
strongly  oppose  any  state  or  federal  legislation  which  may 
be  brought  forth  to  eliminate  and  / or  alter  the  schedule 
of  immunization  of  children  as  recommended  by  the 
medically-accepted  guidelines  of  the  American  Academy 
of  Pediatrics  and/or  the  Advisory  Committee  on 
Immunization  Practices 

RESOLUTION  303 

Adopted  10/22/99 

SUBJECT:  Mammography  Screening  in  Asymptomatic 
Women  Forty  Years  and  Older 
INTRODUCED  BY:  Committee  on  Maternal  and 
Perinatal  Health  and  Committee  on  Public  Health 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
revise  LSMS  policy  to  recommend  annual  screening 
mammograms  and  clinical  breast  examinations  in 
asymptomatic  women  40  years  and  older. 

RESOLUTION  304 

Adopted  as  amended  10/23/99 
SUBJECT:  Emergency  Preparedness 
INTRODUCED  BY:  Committee  on  Public  Health 

RESOLVED,  that  the  president  of  the  Louisiana  State 
Medical  Society  write  a letter  to  the  presidents  of  all  of 
the  component  societies  of  the  Louisiana  State  Medical 
Society  urging  that  those  component  societies  provide 
medical  expertise,  advice  and  manpower  from  among 
their  members,  if  and  when  needed  for  medical 
emergencies,  to  the  parish  emergency  preparedness 
agencies  and  parish  health  units. 

RESOLUTION  305 

Adopted  10/23/99 

SUBJECT:  Louisiana  Child  Birth  Defects  Registry 
INTRODUCED  BY:  Floyd  Buras,  MD,  Delegate, 

Orleans  Parish  Medical  Society 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
endorses  the  establishment  of  a Louisiana  Child  Birth 
Defects  Registry. 


Supplement  66  VOL  152  March  2000  J La  State  Med  Soc 


RESOLUTION  306 

Adopted  as  amended  10/23/99 

SUBJECT:  Discarding  of  Drugs  in  Nursing  Homes 

INTRODUCED  BY:  Committee  on  Geriatrics 

RESOLVED,  that  the  LSMS  encourage  the  Board  of 
Pharmacy  to  promote  policy  or  regulations  that  would 
allow  unused  prescription  medications  from  nursing 
homes  that  are  in  the  original,  unopened  blister/ unit  dose 
packages  to  be  redistributed  to  indigent  clinics  for  the 
medical  needs  of  the  indigent  who  otherwise  have  no 
access  to  necessary  drugs  or  establish  a mechanism  to 
credit  the  Medicaid  program  for  the  value  of  the  unused 
drugs. 

RESOLUTION  307 

Withdrawn 

SUBJECT:  Measles,  Mumps  and  Rubella  Vaccination 
Practices 

INTRODUCED  BY:  Committee  on  Pediatric  Health 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
establish  as  policy  that  the  benefits  of  vaccines  outweigh 
the  risks  and  declares  its  support  for  the  current  vaccine 
schedule  recommendations  and  practice  of  administering 
the  MMR  vaccine  at  12  to  15  months  of  age,  initially,  and 
subsequently  at  age  4 to  6 years,  prior  to  school  entry. 

RESOLUTION  308 

Adopted  as  amended  10/23/99 

SUBJECT:  Use  of  Preventive  Measures  for  Treatment  of 
Disease 

INTRODUCED  BY:  Orleans  Parish  Medical  Society 

RESOLVED,  that  the  LSMS  promote  in  its  members  a 
philosophy  of  using  scientifically-proven  preventive 
measures  for  the  prevention  of  specific  disease  entities. 

RESOLUTION  309 

Adopted  as  amended  10/23/99 

SUBJECT:  Scientific  Justification  for  HCFA  Regulations 
INTRODUCED  BY:  Orleans  Parish  Medical  Society 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
request  that  HCFA  show  scientific  justification  for  its  rules 
and  regulations  and  be  required  to  show  through  cost- 
benefit  analysis  that  these  rules  will  not  add  to  the  cost  of 
health  care,  and  be  it  further 

RESOLVED,  that  the  LSMS  AMA  Delegation  submit  a 
resolution  to  the  AMA  House  of  Delegates  that  asks  the 
AMA  to  request  from  HCFA  the  scientific  justification  for 
its  proposed  rules  and  regulations,  and  that  HCFA  be 
required  to  show,  through  cost-benefit  analysis,  that 


proposed  rules  will  not  add  to  the  cost  of  health  care 
without  corresponding  increase  in  reimbursement. 

RESOLUTION  401 

Adopted  as  amended  10/23/99 

SUBJECT:  Federal  Funding  Reimbursement  Coverage 
Differential 

INTRODUCED  BY:  Committee  on  Maternal  and 
Perinatal  Health 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
engage  in  reasonable  efforts  to  pursue  regulatory  efforts 
to  equalize  federally-funded,  state-directed  reim- 
bursement policy  for  both  women  and  children  within 
the  same  household. 

RESOLUTION  402 

Substitute  resolution  adopted  as  amended  10/23/99 
SUBJECT:  Necessity  to  Have  a License  to  Practice 
Medicine 

INTRODUCED  BY:  Trent  James,  MD,  Delegate,  East 
Baton  Rouge  Parish  Medical  Society 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
requests  that  the  Office  of  the  Commissioner  of  Insurance 
undertake  the  development  of  administrative  rules  which 
would  require  that  any  medical  insurer,  provider,  or  entity 
regulated  by  the  Commissioner  of  Insurance,  utilize  only 
physicians  licensed  in  Louisiana  to  undertake  medical 
necessity  or  appropriateness  of  care  determinations  with 
respect  to  citizens  of  this  state. 

RESOLUTION  403 

Substitute  resolution  adopted  10/23/99 
SUBJECT:  PRO  Project 

INTRODUCED  BY:  Committee  on  Physician  /Patient 
Advocacy 

RESOLVED  that  the  LSMS  request  from  HCFA  that,  if  a 
physician  is  audited  by  the  PRO  for  correct  coding,  that 
the  physician  be  notified  not  only  for  overcoding,  but  also 
for  correct  coding  as  well  as  undercoding,  and  be  it  further 

RESOLVED,  that  the  LSMS  request  that  the  state  PRO 
use  this  information  for  educational  purposes  for  the 
physician  providers  of  Louisiana. 

RESOLUTION  404 

Adopted  as  amended  10/23/99 

SUBJECT:  LSMS  Policy  On  Physician  Negotiating  Units 
INTRODUCED  BY:  Shreveport  Medical  Society 

RESOLVED,  that  the  LSMS  adopt  a policy  to  support 
efforts  at  the  state  and  national  levels  to  secure  the  right 


Supplement  67  VOL  152  March  2000  J La  State  Med  Soc 


for  all  physicians  to  form  local  and  / or  regional  negotiating 
units  consistent  with  our  medical  ethics  and 
professionalism  for  the  purpose  of  collectively  bargaining 
with  managed  care  plans,  insurers,  and  employers  on 
issues  related  to  health  care  quality,  patient  rights,  and 
physician  rights,  and  to  oppose  the  affiliation  of  physician 
negotiating  units  with  labor  unions  and  of  the  negotiating 
units  without  the  right  to  strike,  be  it  further 

RESOLVED,  that  the  LSMS  Board  of  Governors  utilizing 
existing  LSMS  and  AMA  resources  within  the  annual 
budget  establish  during  2000  a communication  policy  and 
plan  to  educate  physicians  and  the  general  public  on  the 
goals,  objectives  and  justifications  for  the  development 
of  physician  negotiating  units  to  bargain  collectively  with 
managed  care  plans,  hospitals,  and  insurance  companies 
on  issues  related  to  quality  health  care,  patients  rights 
and  physicians  rights. 

RESOLUTION  405 

Adopted  as  amended  10/23/99 
SUBJECT:  Public  Communication  on  Differences  in 
Education  and  Professional  Standards  Between 
Physicians  and  Non-Physician  Healthcare  Providers 
INTRODUCED  BY:  Shreveport  Medical  Society 

RESOLVED,  that  the  LSMS  develop  a voluntary 
mechanism  to  implement  in  2000  a comprehensive 
information  and  education  public  service  communication 
plan  to  accomplish  the  following  objectives: 

1.  Develop  television,  print,  or  radio  materials  that 
clearly  define  the  difference  in  education  and  professional 
standards  between  physicians  and  non-physician  health 
care  providers  to  be  disseminated  by  the  component 
societies  as  appropriate. 

2.  Periodically  inform  the  public  via  these  news  releases 
on  the  potential  impact  on  quality  of  care  and  patient 
safety  issues  if  non-physician  healthcare  providers  are 
legislatively  credentialed  to  practice  medicine  with 
prescriptive  rights  in  Louisiana, 

3.  Release  of  these  communication  spots  and  articles 
should  be  timed  to  ensure  broad-based  coverage  of  the 
public  sector  leading  up  to  the  yearly  legislative  session, 

4.  Talking  points  and  issue  papers  be  prepared  and 
disseminated  to  component  society  leadership  to  coincide 
with  the  media  releases  to  ensure  a coordinated  effort  in 
each  phase  of  the  plan  throughout  the  period  leading  to 
the  yearly  legislative  session. 

RESOLUTION  406 

Defeated  10/23/99 

SUBJECT:  Ethical  Conflict  of  Interest  for  Preferentially 
Compensated  Physicians 

INTRODUCED  BY:  Marcus  L.  Pittman,  III,  M.D., 
Councilor,  District  10 


RESOLVED,  that,  in  order  to  preserve  "effective 
professional  peer  review"  (United  States  Code,  Title  42, 
Sec.  402  [11101]),  that  the  Louisiana  State  Medical  Society 
should  communicate  with  and  urge  action  by  the 
Louisiana  State  Board  of  Medical  Examiners  to  consider 
that  physicians  who  are  preferentially  compensated  by  a 
hospital,  (i.e.,  either  compensated  directly  or  indirectly 
through  intermediary  contractual  arrangements,  or  by  a 
similar  agreement  with  another  hospital  in  economic 
competition  with  the  hospital  in  question)  to  be  prohibited 
from  medical  staff  voting,  from  holding  medical  staff 
office,  and  from  participating  in  medical  staff  peer  review 
oversight,  or  else  be  considered  to  be  in  violation  of  the 
Louisiana  Medical  Practice  Act  provision  on 
"unprofessional  conduct." 

RESOLUTION  407 

Defeated  10/23/99 

SUBJECT:  Information  Concerning  Laws  and  Regulations 
Regarding  Health  Insurance  / Managed  Care  Organization 
Practices 

INTRODUCED  BY:  Floyd  A.  Buras,  Jr.,  M.D.,  Delegate, 
Orleans  Parish  Medical  Society 

RESOLVED,  that  the  LSMS  evaluate  the  most  cost- 
effective  means  of  informing  members  about  all  laws  and 
regulations  regarding  health  insurance  and  managed  care 
organization  practices,  and  be  it  further 

RESOLVED,  that  the  LSMS  will  work  in  concert  with 
other  organizations  and  government  bodies  to  provide 
information  about  all  laws  and  regulations  regarding 
health  insurance  and  managed  care  organization  practices 
in  a format  which  can  be  readily  updated  and  easily 
accessible  (e.g.,  manual,  website,  etc.),  and  be  it  further 

RESOLVED,  that  the  LSMS  will  encourage  physicians  to 
seek  appropriate  counsel  to  assist  them  in  the 
interpretation  of  pertinent  laws  and  regulations  regarding 
health  insurance  and  managed  care  organization 
practices. 

RESOLUTION  408 

Adopted  as  amended  10/23/99 

SUBJECT:  Implementation  of  Payment  Timeliness 

Survey 

INTRODUCED  BY:  Orleans  Parish  Medical  Society 

RESOLVED,  that  the  LSMS  conduct  a periodic  survey  of 
the  members  regarding  third-party  payor  timeliness,  and 
be  it  further 

RESOLVED,  that  the  LSMS  consider  using  the  Payment 
Timeliness  Survey  developed  already  by  the  AMA's 


Supplement  68  VOL  152  March  2000  J La  State  Med  Soc 


Advocacy  Resource  Center  for  its  Campaign  to  Promote 
Timely  Payment,  and  be  it  further 

RESOLVED,  that  the  LSMS  publish  the  composite  results 
of  the  periodic  survey  regarding  third-party  payor 
timeliness  to  the  membership  in  Capsules  and/or  the 
Journal  and/or  the  LSMS  website,  consider  dissemination 
to  statewide  media,  and  use  the  data  in  its  own  discussions 
with  managed  care  companies,  business  coalitions,  and 
state  agencies  or  regulatory  bodies  to  effect  positive 
change,  and  be  it  further 

RESOLVED,  that  the  LSMS  publish  the  results  of  the 
periodic  survey  regarding  third-party  payor  timeliness 
on  a regional  and  / or  parish  basis  for  use  by  component 
societies  to  represent  members7  collective  interests  with 
health  insurance  entities,  managed  care  organizations 
and  / or  self-funded  employers  in  their  local  areas. 

RESOLUTION  409 

Substitute  resolution  adopted  10/23/99 
SUBJECT:  Health  Plan  "In-Network"  Hospitals 
INTRODUCED  BY:  Orleans  Parish  Medical  Society 

RESOLVED,  that  the  LSMS  communicate  in  writing  with 
the  Department  of  Insurance  about  the  current  practice 
of  some  health  insurance  and  managed  care  organizations 
to  decide,  for  payment  purposes,  that  an  "in-network" 
hospital  will  be  paid  the  "out-of-network"  hospital  fees 
when  the  patient  was  treated  at  an  "in-network"  hospital 
by  an  "out-of-network"  physician,  and  therefore  be  it 
further 

RESOLVED,  that  the  LSMS  request  that  the  Department 
of  Insurance  notify  the  health  insurance  and  managed  care 
organizations  that  when  they  pay  "in-network"  hospitals 
at  the  "out-of-network"  fee  schedule,  when  patients  are 
treated  at  the  "in-network"  hospital  by  an  "out-of- 
network" physician,  that  they  are  in  violation  of  Louisiana 
statutes  and  / or  regulations,  and  therefore  be  it  further 

RESOLVED,  that  the  LSMS  publish  information  about 
the  statutes  and  / or  regulations  regarding  the  practice  of 
health  insurance  and  managed  care  organizations  to 
decide,  for  payment  purposes,  that  an  "in-network" 
hospital  will  be  paid  the  "out-of-network"  hospital  fees 
when  the  patient  was  treated  at  an  "in  network7'  hospital 
by  an  "out-of-network"  physician,  and  that  when  this 
occurs,  the  health  insurance  and  managed  care 
organizations  are  in  violation  of  these  statutes  and  / or 
regulations. 


RESOLUTION  410 

Adopted  as  amended  10/23/99 
SUBJECT:  Proper  Notification  and  Education 
Regarding  Healthcare  Provider  Shortage  Areas  by 
Carrier 

INTRODUCED  BY:  Orleans  Parish  Medical  Society 

RESOLVED,  that  the  LSMS  should  immediately 
communicate  with  the  Medicare  Part  B Carrier  to  request 
notification  of  all  physicians  located  in  Healthcare 
Provider  Shortage  Areas  of  their  eligibility  for  the 
incentive  payment  of  10%  of  the  amount  paid  by 
Medicare,  and  be  it  further 

RESOLVED,  that  the  LSMS  communicate  with  the 
Medicare  Part  B Carrier  regarding  the  current  regulations 
which,  upon  notification  that  an  area(s)  has  been  classified 
(or  declassified)  as  a Healthcare  Provider  Shortage  Area, 
the  Medicare  Part  B Carrier  has  the  responsibility  of 
informing  "the  applicable  physician  community  of  the 
status  of  the  area,  the  requirements  for  eligibility  for  the 
incentive  payment,  and  the  mechanism  for  claiming 
payment,"  and  be  it  further 

RESOLVED,  that  the  LSMS  publish  information  to  the 
membership  regularly  regarding  the  Healthcare  Provider 
Shortage  Area  incentive  payment  in  LSMS  publications 
and  on  the  website,  and  be  it  further 

RESOLVED,  that  the  LSMS  assist  members  by  providing 
copies  of  the  current  Healthcare  Provider  Shortage  Area 
designations  upon  request,  and  be  it  further 

RESOLVED,  that  the  AMA  delegation  of  the  LSMS  submit 
a resolution  to  the  AMA  House  of  Delegates  regarding 
enforcement  of  the  Medicare  Part  B carriers7 
responsibilities  to  notify  all  providers  and  providers 
located  in  Healthcare  Provider  Shortage  Areas  of  the 
incentive  payment,  and  be  it  further 

RESOLVED,  that  LSMS  contact  members  of  the  Louisiana 
Congressional  delegation  regarding  the  development  of 
legislation  which  would  require  HCFA  to  clarify  and 
enforce  the  Medicare  Part  B carriers7  responsibility  to 
notify  all  providers  and  provider  located  in  Healthcare 
Provider  Shortage  Areas  of  the  incentive  payment. 

RESOLUTION  411 

Substitute  resolution  adopted  10/23/99 
SUBJECT:  Code  of  Conduct  for  Health  Insurance 
Entities /Managed  Care  Organizations 
INTRODUCED  BY:  Orleans  Parish  Medical  Society 


Supplement  69  VOL  152  March  2000  J La  State  Med  Soc 


RESOLVED,  that  the  Louisiana  State  Medical  Society 
Board  of  Governors  charge  an  appropriate  committee  to 
develop  a Code  of  Conduct  for  health  insurance  entities 
and  managed  care  organizations  for  approval  by  the 
House  of  Delegates  in  2000,  and,  upon  approval  by  the 
House  of  Delegates,  to  disseminate  the  proposed  Code  of 
Conduct  for  Health  Insurance  Entities  and  Managed  Care 
Organizations  to  the  Department  of  Insurance  as  a model, 
and  therefore  be  it  further 

RESOLVED,  that  the  LSMS  Board  of  Governors,  when 
charging  the  appropriate  committee  to  develop  a Code 
of  Conduct,  request  that  it  include,  but  not  be  limited  to, 
practices  and  policies  regarding  timely  credentialing  of 
providers,  uniformity  of  contracts,  provision  of  updated 
physician  directories  and  provider  manuals,  publication 
of  fee  schedules  by  procedure  code,  inclusion  of  a clear 
glossary  of  terminology  (e.g.,  clean  claim,  participating 
vs.  non-participating),  provision  of  information  regarding 
co-pays,  and  publication  of  legitimate  appeals  process. 

RESOLUTION  412 

Referred  to  the  Board  of  Governors  10/23/99 
SUBJECT:  Establishment  of  Service  to  Review  Health 
Insurance  / Managed  Care  Organization  Contracts  and 
Provide  Comparison  Data  to  Members 
INTRODUCED  BY:  Orleans  Parish  Medical  Society 

RESOLVED,  that  the  Louisiana  State  Medical  Society 
establish  a clearing  office  to  analyze  physician  contracts 
and  present  comparison  data  so  that  physician  members 
can  better  evaluate  the  relative  merits  and  demerits  of 
the  particular  physician  contract  at  hand. 

RESOLUTION  413 

Withdrawn 

SUBJECT:  Risk  Management  Educational  Program 
INTRODUCED  BY:  Michael  Ellis,  MD,  Immediate  Past 
President 

RESOLVED,  that  the  concept  of  a risk-management 
educational  program  for  physicians  with  unusual 
numbers  of  malpractice  claims  be  referred  to  the  Board 
of  Governors  for  design  of  the  program,  and  interaction 
with  the  Louisiana  State  Board  of  Medical  Examiners  and 
the  Louisiana  Patient  Compensation  Fund,  as  well  as 
efforts  to  assure  that  appropriate  regulations  or  legislation 
have  been  implemented,  with  a follow-up  report  to  the 
2000  House  of  Delegates  as  to  the  feasibility  of  enacting 
such  a program. 


Supplement  70  VOL  152  March  2000  J La  State  Med  Soc 


2000  Budget 


INCOME 
Membership  Dues 

Active  Dues 
Active  Part-Time 
Working  Dues  Exempt 
Academic  Dues 
Military  Dues 
Resident  Dues 
Corresponding  Dues 
Delinquent  Fees 
AMA  Commissions 
Subtotal 


Interest 


Managing  Agency  Account 
Journal  Note 

Administrative  Services 
Journal 

Educational  Research  Found. 
Physician's  Health  Foundation 
Note  Receivable-Journal 
Subtotal 

Miscellaneous  Income 


1,687,500.00 

1,000.00 

3,000.00 

750.00 

1.500.00 
14,425.00 

250.00 
50.00 

3.500.00 


20,580.00 

2,500.00 

2,500.00 

9,000.00 


1,711,975.00 

342,000.00 

3,300.00 


34,580.00 

121,125.00 


TOTAL  INCOME 


2,212,980.00 


EXPENSES 


Appropriations 

Rent 

Journal  Subscriptions 
Presidential  Honorarium 
Expense  of  Presidency 
LSMS  Alliance 

Subtotal 


Staff 


Executive  Staff 
Administrative  Staff 
Christmas  Gifts 

Subtotal 

Payroll  Taxes  and  Benefits 

Payroll  Taxes 
Health /Life  Ins. 
Retirement  Plan 
Workers  Comp.  Ins. 
Pension  Supplement 
P/R  Processing  Fees 
Subtotal 


Administration 

Equipment  Lease 
Fum.  and  Equip. 
Maint.  and  Repairs 
Postage 

Printing  Supplies 
Supplies  and  Materials 
Computer  Labels 
Telephone  Exp. 

Dues 

Publications 


214,500.00 

77,235.00 

25.000. 00 
2,500.00 

15.000. 00 


631.150.00 

282.130.00 
15,000.00 


68,000.00 

54.000. 00 

70.000. 00 
5,600.00 

3.000. 00 

2.000. 00 


15.000. 00 

10.000. 00 

13.000. 00 

20.000. 00 

15.000. 00 

20.000. 00 

500.00 

32,000.00 

9,500.00 

9,000.00 


334,235.00 


928,280.00 


202,600.00 


Supplement  71  VOL  152  March  2000  J La  State  Med  Soc 


Directories 

60,000.00 

Vehicle /Utility 

6,750.00 

Computer  Support 

10,000.00 

Subtotal 

220,750.00 

Legislative  Activities 

In-State  Travel 

5,000.00 

Legislative  Entertainment 

20,000.00 

Special  Legislative  Reception 

10,000.00 

Washington,  DC  Mardi  Gras 

10,000.00 

Meetings 

2,000.00 

Legislative  Reporting 

4,000.00 

Council  on  Legislation 

2,000.00 

LAMPAC  Exp. 

10,000.00 

Capitol  First  Aid  Station 

6,000.00 

Lobbying  Services 

27,500.00 

Misc.  Legislative  Distr.  Match 

3,000.00 

Subtotal 

99,500.00 

Annual  Meeting 

House  of  Delegates 

42,500.00 

Meetings  and  Meals 

15,000.00 

President-Elect  Rec. 

12,500.00 

Subtotal 

70,000.00 

Meetings 

In-State  Travel 

8,500.00 

Out-of-State  Travel 

25,000.00 

Board  of  Governors 

22,500.00 

Budget  and  Finance 

1,500.00 

Leadership  Conference 

0.00 

Subtotal 

57,500.00 

AMA  Delegation 

AMA  Travel  and  Meetings 

55,000.00 

AMA  Young  Physician  Sec. 

6,000.00 

AMA  Campaign 

0.00 

Subtotal 

61,000.00 

Legal  Expense 

24,540.00 

Audit 

6,500.00 

Investment  Expense 

36,000.00 

Public  Relations  Projects 

7,500.00 

Corporate  Insurance 

21,500.00 

Membership  Communications 

75,000.00 

Staff  Training/Education 

5,000.00 

Seminars  / Workshops 

22,000.00 

CME  Accreditation  Program 

16,000.00 

Recruitment  Program 

16,000.00 

Committees 

Travel,  Research,  Printing,  Meeting  Expenses 

12,610.00 

Resident  Association  Support 

4,000.00 

Miscellaneous  Expenses 

5,000.00 

Capital  Reserves 

0.00 

Resolutions  w/Fiscal  Notes 

42,700.00 

TOTAL  EXPENDITURES 

2,268,215.00 

Use  of  Undesignated  Reserves  for  Operating  Expenses 

55,235.00 

INCOME  OVER  EXPENSES 

0.00 

Supplement  72  VOL  152  March  2000  J La  State  Med  Soc 


President’s  Address 


Address  by  Leo  L.  Lowentritt,  to  the  LSMS  House  of  Delegates 

October  22,  1999 


To  say  the  least,  it  has  been  a very  busy  year.  Serv- 
ing as  President  of  the  LSMS  is  a tremendous  chal- 
lenge and  great  honor.  It  has  been  an  unforgettable 
experience  and  I hope  I have  contributed  to  the  future  of 
organized  medicine  in  some  small  way 

My  objectives  for  the  past  year  were  the  1999  Legisla- 
tive Session,  improved  LSMS  communication,  grassroots 
organization,  increased  membership,  managed  care  re- 
form, meeting  with  component  societies,  and  building 
bridges  to  nonmembers  and  minority  medical  societies. 
In  addition,  I focused  on  maintaining  a good  working  re- 
lationship with  the  Department  of  Insurance  under  Com- 
missioner Jim  Brown  and  the  Department  of  Health  and 
Hospital  under  Secretary  David  Hood.  Finally,  on  the 
federal  level,  I participated  in  the  AMA  delegation  and 
promoted  the  LSMS  and  medicine  in  Washington. 

To  prepare  for  the  session,  the  LSMS  developed  bet- 
ter ways  to  communicate  with  its  members.  Dr.  Benson 
Scott  helped  with  the  initial  development  of  the  LSMS 
web  site.  Subsequently,  the  site  was  further  refined  and 
enhanced  by  our  LSMS  staff. 

E-mail  is  a relatively  new  and  inexpensive  way  for 
the  LSMS  to  communicate  with  its  members.  We  now 
have  the  capability  to  e-mail  to  more  than  fifteen  hun- 
dred members.  Obviously,  as  we  receive  additional  e- 
mail  addresses,  this  capability  will  improve.  We  imple- 
mented a system  for  blast  faxes,  which  also  increased  com- 
munication with  our  members.  Fax  communication  was 
used  extensively  during  the  legislative  session. 

Dave  Tarver  (EVP)  is  sending  out  a monthly  Execu- 
tive Memo  newsletter  to  the  LSMS  leadership.  The  Jour- 
nal was  further  improved  and  continued  to  prosper  un- 
der the  leadership  of  Cathy  Lewis.  As  directed  by  the 
House  of  Delegates,  I submitted  monthly  articles  to  the 
Journal  as  the  President's  Message.  It  is  exciting  to  have 
your  own  page  to  convey  your  thoughts  to  the  entire 
membership.  Under  the  direction  of  Cathy  Lewis  and 
Candace  Davis,  Capsules  continued  to  expand  and  reflect 
current  information.  The  Pelican  campaign  newsletter  was 
successfully  used  to  promote  the  candidacy  of  Dr.  Don 
Palmisano  for  AMA  Board  of  Trusties. 

Amy  Phillips,  General  Counsel,  continued  to  enhance 
the  efficiency  and  expertise  of  our  legal  department  with 
her  extensive  experience  and  skills. 


Under  Jeanette  Harmon,  the  continuing  medical  edu- 
cation program  has  continued  to  expand  its  operations 
and  is  prepared  for  the  increased  demand  resulting  from 
the  recently  enacted  statute  requiring  physicians  to  meet 
continuing  education  requirements. 

I continued  to  pursue  development  of  the  Specialty 
Society  Committee  (SSC)  under  the  combined  leadership 
of  Dr.  Thomas  Bertuccini  (Chair)  and  Dr.  Wayne  Gravois 
(Vice  Chair).  The  SSC  provided  access  to  many  nonmem- 
bers as  well  as  to  the  leaders  of  the  Louisiana  specialty 
societies.  This  forum  proved  invaluable  as  a source  of 
information  and  to  help  resolve  issues  before  they  became 
problems.  It  is  too  late,  and  counterproductive,  to  debate 
our  differences  in  open  legislative  committee  hearings. 
Many  of  the  specialty  societies  served  as  an  excellent  con- 
duit for  communication  to  their  members  to  lobby  the 
legislature.  It  is  my  hope  that  the  SSC  will  continue  to  be 
nourished  and  expanded. 

I worked  to  expand  participation  of  the  LSMS  Alli- 
ance in  our  legislative  efforts.  In  fact,  the  Alliance  was  a 
great  help  in  our  legislative  grassroots  initiative  this  year. 
Under  the  aggressive  leadership  of  Karen  Depp,  I see  an 
expanded  and  more  integrated  role  for  the  Alliance.  The 
Alliance  will  resume  their  Annual  Meetings  at  the  same 


Dr.  Leo  Lowentritt  addresses  the  House  of  Delegates 
at  the  120th  Annual  Meeting. 


Supplement  73  VOL  152  March  2000  J La  State  Med  Soc 


time  as  the  LSMS  House  of  Delegates  commencing  in  Oc- 
tober, 2000.  This  should  increase  the  attendance  of  both 
organizations. 

I strongly  encouraged  a grassroots  initiative  at  the 
component  society  level  and  they  responded.  The  Loui- 
siana legislators  related  to  us  that  this  was  the  largest  out- 
pouring of  mail  and  communication  from  the  LSMS  that 
they  had  ever  seen.  By  the  middle  of  the  session,  most 
legislators  were  well  aware  of  our  issues.  Without  this 
support,  we  would  never  have  been  so  successful. 

Our  newest  lobbyist,  David  Kemmerly,  was  well  re- 
ceived by  our  faithful  Sharon  Knight  and  Kerry  Cooley. 
His  presence  was  immediately  felt.  Because  of  the  im- 
mense number  of  bills  introduced  this  session  the  LSMS 
hired  additional  contract  lobbyists.  Our  contract  lobby- 
ists, Harris,  DeVille  and  Associates  and  former  state  rep- 
resentative Alphonse  Jackson,  were  extremely  instrumen- 
tal in  our  success  this  session.  Without  their  experience, 
legislative  relationships,  and  credibility,  we  would  not 
have  been  able  to  defeat  such  issues  as  psychology  pre- 
scribing, physician  assistant  prescribing,  childhood  im- 
munization schedule  changes,  increases  in  the  medical 
malpractice  cap  and  unwanted  changes  to  the  Louisiana 
State  Board  of  Medical  Examiners.  In  addition,  our  con- 
tract lobbyists  also  used  their  considerable  talents  to  help 
the  LSMS  pass  key  legislation,  such  as  mental  health  par- 
ity. 

The  Louisiana  Psychiatric  Medical  Association's 
(LPMA)  contract  lobbyist,  Vera  Olds,  worked  diligently 
with  the  LSMS  to  defeat  the  psychology  prescribing  is- 
sue. After  a five-year  effort,  Ms.  Olds  also  helped  pass  a 
mandate  for  health  insurance  coverage  of  13  diagnoses 
of  severe  mental  illness.  The  coordinated  efforts  of  the 
DGA  staff,  the  LSMS  contract  lobbyists  and  Ms.  Olds  were 
critical  to  our  success  on  these  two  priority  issues. 

I initiated  contact  with  the  Louisiana  Legislative  Black 
Caucus  through  Representative  Israel  Curtis.  I was  re- 
ceived warmly  by  Representative  Sherman  Copelin, 
Chairman,  at  a meeting  of  the  Corporate  Roundtable,  an 
organization  founded  by  the  Black  Caucus.  In  fact,  the 
LSMS  has  been  invited,  and  intends  to  join  the  Corporate 
Roundtable.  We  hope  this  will  be  an  enduring  and  mu- 
tually beneficial  relationship. 

Our  success  in  the  1999  Regular  Legislative  Session 
was  one  of  the  best  on  record.  Not  one  bill  was  enacted 
into  law  which  the  LSMS  actively  opposed.  We  blocked 
the  psychologists  attempt  to  obtain  prescriptive  author- 
ity. The  physicians'  assistant's  prescriptive  authority  bill 
was  soundly  defeated.  The  hypnotherapists'  attempt  to 
establish  their  own  licensing  board  was  defeated  in  com- 
mittee. A strong  healthcare  coalition  passed  mandated 
health  insurance  coverage  for  13  diagnoses  of  the  most 
severe  mental  illnesses.  This  was  a major  victory  that 
had  been  sought  for  many  years  and  was  vehemently  op- 


posed by  business  and  insurance  interests.  Several  at- 
tempts to  increase  the  medical  malpractice  cap  of  $500,000 
were  defeated.  An  attempt  to  raise  attorney  chairman 
fees  to  $5,000  for  medical  review  panels  failed  to  pass  even 
when  amended  to  $3,000.  Blood  liability  and  prescrip- 
tion and  peremption  periods  for  liability  were  passed  re- 
ducing liability  for  Hepatitis  C prior  to  1992  secondary  to 
blood  transfusion.  We  fought  off  attempts  to  place  a phy- 
sician nominated  by  the  Louisiana  Hospital  Association 
and  a nonvoting  APRN  on  the  Louisiana  State  Board  of 
Medical  Examiners.  However,  we  did  support  a provi- 
sion instituting  term  limits  for  the  members  of  the  board. 
The  LSMS  can  now  only  nominate  four,  instead  of  six  of 
the  seven  members  of  the  board.  The  Louisiana  Medical 
Association  will  nominate  two,  and  the  Louisiana  Acad- 
emy of  Family  Practice  will  nominate  one.  Unfortunately, 
we  were  unsuccessful  in  passing  legislation  to  help  pro- 
tect the  PCF.  We  attempted  to  provide  for  reimbursement 
schedules  for  the  payment  of  future  medical  care.  This 
could  have  saved  the  PCF  more  than  $3.7  million  a year. 
These  are  only  a few  of  the  approximately  750  bills  that 
affected  medicine  in  some  way. 

I attended  the  Annual  Meeting  of  the  Louisiana  Chap- 
ter of  the  American  Association  from  India.  This  was  the 
first  time  an  LSMS  President  had  spoken  to  this  organi- 
zation. Dr.  Gupta,  President,  and  their  members  were 
extremely  cordial  and  interested  in  my  comments.  I hope 
their  organization  will  take  advantage  of  our  invitation 
to  be  "official  observers"  at  our  House  of  Delegates.  I 
emphasized  that  we  were  all  physicians  in  the  House  of 
Medicine  and  shared  the  same  or  similar  interests  and 
concerns  for  our  patients. 

My  predecessor.  Dr.  Mike  Ellis,  has  continued  his  con- 
tacts with  the  Louisiana  Medical  Association  (LMA).  I 
hope  that  the  LMA  will  also  accept  our  invitation  to  be 
"official  observers"  at  our  House  of  Delegates. 

Membership  continues  to  be  an  area  of  concern.  I 
have  reached  out  to  all  the  component  societies  and  en- 
couraged them  to  be  inventive  and  work  to  both  recruit 
new  members  and  to  retain  our  current  membership.  We 
are  in  friendly  competition  with  the  specialty  societies, 
and  the  hospitals,  for  physicians'  interest  and  time. 

Under  the  guidance  of  Bryan  LaHaye,  LSMS  Direc- 
tor of  Membership  & Finance,  interest  in  membership  re- 
cruitment has  been  made  a priority.  Hopefully,  this  new 
emphasis  will  be  vigorously  pursued  as  the  future  of  the 
LSMS  depends  on  reaching  out  to  more  physicians. 

To  reach  new  leaders,  the  LSMS  held  the  second  an- 
nual Leadership  Conference.  It  was  well  attended  and 
will  be  expanded  yearly.  Under  the  direction  of  our  new 
membership  chairman.  Dr.  Eduardo  Rodriguez,  the  first 
Membership  Summit  will  be  held  in  November  with  a 
facilitator  to  encourage  new  ideas.  Hopefully  you  will 
see  results  in  the  form  of  renewed  interest  in  member- 


Supplement  74  VOL  152  March  2000  J La  State  Med  Soc 


ship.  If  the  LSMS  is  to  attract  new  members  and  retain 
our  current  members,  we  must  give  value.  Value  is  dif- 
ferent for  different  groups.  The  LSMS  must  think  "out- 
side the  box"  to  find  ways  to  reach  all  physicians.  We  must 
first  identify  Louisiana  physicians  and  survey  their  needs. 
We  must  then  work  to  satisfy  those  needs  and  give  them 
value  in  return  for  their  dues. 

Our  legislative  effort  is  central  to  all  physicians'  needs. 
Managed  care  was  a top  priority  this  year.  The  Managed 
Care  Liaison  Committee  was  extremely  active  under  the 
skillful  direction  of  Dr.  Jay  Shames,  Dr.  Van  Cullotta,  Dr. 
Floyd  Buras,  Dr.  Mike  Ellis,  and  Amy  Phillips,  LSMS  Gen- 
eral Counsel,  and  others.  Many  of  the  House  of  Delegates 
resolutions  of  last  year  were  incorporated  into  bills  and 
ultimately  enacted  into  law.  There  is  still  much  work  to 
be  done.  We  will  continue  to  work  with  the  Office  of 
Health  Insurance  within  the  Department  of  Insurance,  to 
draft  rules  and  regulations  to  implement  the  intent  of 
these  legislative  instruments. 

Commissioner  Brown  and  his  Deputy  Commissioner, 
Richard  O'Shee,  were  great  to  work  with  this  year.  The 
Department  of  Insurance  (DOI)  and  the  LSMS  sponsored 
many  bills  that  went  on  to  become  law.  All  insurance 
sold  in  the  state  must  comply  with  Louisiana  law.  Re- 
quirements for  entities  making  medical  necessary  deci- 
sions were  established.  This  includes  the  right  to  sue  such 
entities  for  negligent  acts.  We  expect  this  provision  of 
the  law  to  be  litigated  by  the  insurance  industry.  Timely 
payment  legislation  established  procedures  and  time 
frames  for  the  prompt  payment  of  health  services  by  both 
HMOs  and  health  insurance  plans.  Health  insurance  ben- 
efit cards  must  display  the  responsible  party  for  the  cov- 
erage and  eliminate  confusion  on  what  plans  are  regu- 
lated and  what  plans  are  exempt  under  federal  law. 
HMOs  must  provide  coverage  for  clinical  trial  treatment 
for  life  threatening  conditions  such  as  cancer. 

The  LSMS  staff  and  its  officers  met  several  times  with 
Secretary  David  Hood  of  the  Department  of  Health  and 
Hospitals  (DHH).  We  have  continued  to  develop  a close 
working  relationship  with  DHH.  With  Secretary  Hood's 
help,  we  were  able  to  initiate  a small  increase  in  fees  for 
three  specific  CPT  codes,  and  maintain  at  least  the  same 
reimbursement  level  for  the  Medicaid  program.  The  ex- 
ecutive budget  submitted  to  the  legislature  by  the  Gover- 
nor called  for  a cut  to  Medicaid.  DHH  fought  to  main- 
tain funding  for  Medicaid  at  its  present  level.  Money  from 
the  tobacco  settlement  was  used  to  maintain  the  present 
funding  level  of  Medicaid. 

The  LSMS  will  continue  its  efforts  to  obtain  increases 
for  private  physician  reimbursement.  Secretary  Hood  is 
well  aware  of  the  low  reimbursement  levels  for  physi- 
cians and  is  trying  to  find  ways  to  secure  additional  fund- 
ing for  raising  physician  reimbursement. 

We  also  discussed  with  Secretary  Hood  fraud  and 


abuse  detection,  and  the  LSMS  was  assured  that  mistakes 
in  ordinary  coding  were  not  the  primary  target  for  such 
endeavors.  Our  LSMS  attorneys  reviewed  in  detail  the 
DHH  Surveillance  and  Utilization  Review  System  regu- 
lations and  were  able  to  elicit  significant  changes. 

My  Washington  agenda  has  been  full  with  three  trips. 
We  visited  all  of  the  members  of  the  Louisiana  congres- 
sional delegation  or  their  aides  on  our  annual  Washing- 
ton legislative  visit.  Dave  Kemmerly  prepared  an  excel- 
lent briefing  booklet  for  the  LSMS  representatives  which 
included  Dr.  Clint  Lewis,  Dr.  Bill  Hall,  Dr.  Keith  DeSonier, 
Dr.  Bill  Cassidy,  Dr.  Floyd  Buras,  Dr.  David  Treen,  Dr.  Ri- 
chard Paddock,  Dave  Tarver,  Dave  Kemmerly  and  Susan 
D' Antoni.  We  met  with  the  federal  legislation  division  of 
the  AMA  who  briefed  us  on  current  healthcare  issues  be- 
fore our  meetings  with  members  of  our  congressional  del- 
egation. Key  issues  focused  on  in  the  meetings  with  our 
delegation  were  fraud  and  abuse.  Medicare  reform,  and 
patients'  rights. 

Mardi  Gras  in  Washington  has  become  an  annual 
event  of  the  LSMS.  It  is  a great  time  to  meet  with  our 
Louisiana  Delegation  on  an  informal  basis.  Dr.  Clint  Lewis 
and  his  wife,  Nancy,  Dave  and  Felicity  Kemmerly,  and 
Beverly  and  I made  and  renewed  many  important  con- 
tacts among  our  congressional  delegations  and  their  staffs. 

My  last  trip  was  to  honor  Senator  Breaux  who  re- 
ceived the  Nathan  Davis  Award  presented  by  the  AMA. 
He  was  nominated  by  the  LSMS  and  was  selected  for  his 
work  and  expertise  in  a variety  of  key  health  policy  ar- 
eas. As  Chairman  of  the  National  Bipartisan  Commis- 
sion on  the  Future  of  Medicare,  he  worked  to  ensure  that 
senior  citizens  have  a strong  Medicare  program.  The 
Commission  did  not  reach  the  required  super  majority 
for  a consensus  report,  however,  its  findings  may  serve 
as  the  basis  for  a bill  that  will  likely  be  introduced  and 
debated  before  the  Congress. 

The  AMA  leadership  conference  was  held  in  Phoe- 
nix. It  is  always  interesting,  and  well  worth  our  leaders 
attending.  Y2K  was  a major  concern.  As  usual,  Pat  Clark 
gave  her  excellent  TV  and  interview  lectures.  Fraud  and 
abuse  and  compliance  were  big  topics.  AMAP  was  again 
a controversial  topic  of  discussion.  Managed  care  and 
many  of  its  following  problems  were  extensively  dis- 
cussed: arbitrary  denials,  external  review  procedures, 
health  plan  accountability  when  negligent  medical  deci- 
sions cause  injury  or  death,  gag  practices,  access  to  ad- 
equate information  from  health  plans,  prudent  layperson 
standards  for  emergency  services,  choice  of  care,  conti- 
nuity of  medical  care,  access  to  specialty  care,  preemp- 
tion of  state  laws  by  federal  legislation.  The  keynote 
speaker,  former  President  George  Bush,  was  fantastic.  Dr. 
Clint  Lewis  and  Jeanette  Harmon  also  attended.  It  was  a 
great  conference  to  prepare  our  future  leaders. 

I attended  the  AMA  Interim  Meeting  in  Hawaii.  It 


Supplement  75  VOL  152  March  2000  J La  State  Med  Soc 


was  a tough  assignment,  but  someone  had  to  do  it!  AMAP 
was  once  again  extensively  discussed.  There  were  no  fi- 
nal conclusions,  and  the  AM  A was  to  continue  the  project. 
There  was  little  enthusiasm  voiced  for  AMAP.  Member- 
ship was  a common  problem  to  all  states  as  well  as  the 
AMA.  The  Advocacy  Recourse  Center  (ARC)  rolled  out 
its  initial  set  of  state  advocacy  campaigns.  I was  extremely 
impressed  with  the  materials  as  something  valuable  for 
use  by  state  societies.  One  of  the  highlights  of  the  meet- 
ing was  the  vote  to  pursue  collective  negotiation  for  phy- 
sicians. However,  the  AMA  Board  of  Trustees  didn't  fi- 
nalize action  on  this  house  mandate.  This  created  much 
discussion  in  Chicago  for  the  annual  AMA  meeting. 

For  the  AMA  Annual  Meeting  in  Chicago,  the  main 
topic  was  collective  negotiation  for  physicians.  The  final 
conclusion  was  that  the  AMA  would  assist  employed  phy- 
sicians and  certain  residents  who  want  to  establish  col- 
lective bargaining  units.  It  is  not  currently  legal  for  self- 
employed  physicians  to  collectively  negotiate.  Thus,  the 
AMA  action  would  only  apply  to  approximately  one  in 


seven  physicians.  Before  forming  collective  bargaining 
units,  the  AMA  would  encourage  negotiation  with  the 
assistance  of  its  legal  counsel.  A "no  strike"  policy  would 
be  observed  for  five  years.  Another  focus  at  the  meeting 
was  membership.  The  AMA  Membership  Task  force 
agreed  to  continue  its  work. 

The  Louisiana  physician  must  be  made  to  realize  that 
if  the  LSMS  did  not  exist,  we  would  have  to  invent  it. 
The  LSMS  is  the  premier  advocate  for  patients  and  phy- 
sicians in  Louisiana.  It  is  a volunteer  organization.  This 
is  our  Medical  Society.  Let's  make  it  the  best  that  it  can 
be. 

This  report  would  not  be  complete  without  my  heart- 
felt thanks  to  the  excellent,  dedicated  staff  of  the  LSMS. 
Until  you  have  worked  with  this  professional  group  of 
men  and  women,  interested  in  good  medicine,  and  com- 
mitted to  the  welfare  of  our  patients,  and  our  physicians, 
you  cannot  appreciate  the  support  that  they  have  given 
me.  It  has  been  a great  year!  They  made  it  happen! 


Dr.  Lowentritt  thanks  the  LSMS  staff  for  their  hard  work. 


Supplement  76  VOL  152  March  2000  J La  State  Med  Soc 


Inaugural  Address 


Address  by  C.  Clinton  Lewis,  MD,  at  the  Installation 

October  22,  1999 


Thank  you  for  your  confidence  in  electing  me 
president  of  this  august  organization.  It  is 
awe-inspiring  to  be  responsible  for  serving  this  dis- 
tinguished group  of  6,700  doctors,  doctors  in  training,  and 
the  patients  who  depend  on  our  care.  I have  been  ex- 
tremely privileged  to  have  worked  beside  a truly  out- 
standing president.  Dr  Leo  Lowentritt.  I shall  always  be 
grateful  for  his  wise  counsel.  He  has  served  the  LSMS  in 
an  exemplary  manner,  and  we  should  all  be  proud  of  his 
dedication  to  medicine  and  to  the  LSMS. 

I would  like  to  thank  the  numerous  people  who  have 
helped  me  learn  more  about  the  LSMS:  our  past  presi- 
dents, current  officers,  and  committee  chairmen;  people 
with  whom  I have  served  on  committees;  people  who 
have  always  been  encouraging;  those  who  set  the  example 
I wanted  to  emulate;  and  Mr.  Dave  Tarver  and  the  staff 
of  the  LSMS. 

Then  I look  at  this  group,  and  I wonder  how  each  of 
us  got  here,  how  we  became  physicians  in  the  first  place. 
It  is  interesting  to  know  what  makes  a person  study  medi- 
cine, become  a physician.  When  I was  a small  boy  my 
aunt.  Dr.  Edith  Rigsby,  fascinated  me  with  her  stories  of 
medical  school.  Her  love  of  medicine  and  her  compas- 
sion for  her  patients  made  a permanent  impression  on 
my  mind.  As  not  many  women  studied  medicine  in  her 
day,  she  was  also  fiercely  proud.  Last  year  she  celebrated 
her  50th  year  as  a physician. 

We  are  all  here  in  this  room,  in  this  profession,  for 
many  different  reasons.  But  one  common  thread  is  im- 
portant: We  all  care  enough  to  be  part  of  this  group  and 
to  do  what  we  can  to  help  Louisiana  medicine  achieve  its 
full  potential. 

We've  all  heard  and  seen  much  about  the  new  mil- 
lennium. This  unique  time  in  history  stirs  a need  to  make 
major  strides  in  our  fields  of  endeavor,  to  achieve  some- 
thing truly  outstanding,  to  re-evalutate  our  priorities,  to 
become  someone  who  makes  a difference  in  this  world. 

You  would  not  be  here  tonight  if  you  did  not  care 
nor  feel  that  the  LSMS  can  make  a difference  in  Louisi- 
ana. I don't  need  to  ask  you  to  be  committed  to  Louisiana 
medicine,  because  by  your  presence  you  already  are.  But 
I can  tell  you  that  it  will  take  each  of  you  and  the  societies 
you  represent  to  do  the  job  we  must  accomplish.  The  task 


Dr.  C.  Clinton  Lewis  addresses  the  House  of  Del- 
egates at  the  120th  Annual  Meeting. 

of  working  on  committees  while  at  the  same  time  prac- 
ticing medicine  and  being  a father,  mother,  husband,  or 
wife  is  not  an  easy  one. 

But  we  as  physicians  know  all  too  well  what  hard 
work  is.  We  studied  diligently  in  college  to  get  into  medi- 
cal school,  and  in  residencies  most  of  us  know  how  it  feels 
to  pull  a 24-  to  36-  to  48-hour  or  longer  shift.  No  single 
profession  knows  the  meaning  of  hard  work  any  better 
than  physicians. 

We  probably  all  had  someone  encouraging  us  to 
work  hard.  In  my  case,  I had  a disciplinarian,  school- 
teacher mother  and  a businessman,  banker  father.  There 
was  no  room  for  "can't  do"  excuses  for  difficult  tasks. 
I'm  sure  many  of  you  had  similar  situations. 

And  we  are  all  acutely  aware  of  the  requirements 
and  challenges  facing  physicians  today.  But  I know  that 
the  physicians  of  Louisiana  can  meet  these  encounters 
head-on.  As  I look  into  this  group  of  LSMS  members,  I 
see  talented,  brillant,  and  dedicated  persons  I have 
worked  with  over  the  years.  I know  what  you  can  do  when 
we  all  work  together.  I know  that  you  have  your  patients' 
welfare  first  and  foremost  in  your  minds. 

We  are  a diverse  state  and  thus  a diverse  society,  as 
well.  Herein  lies  our  strength.  I have  seen  you  grasp  new 
ideas,  become  enthused,  and  turn  these  ideas  into  worth- 


Supplement  77  VOL  152  March  2000  J La  State  Med  Soc 


while  commitments.  I have  also  seen  you  finely  turn  on- 
going projects  into  amazingly  meaningful  undertakings. 

And  at  the  AMA  meeting  this  summer  in  Chicago, 
Don  Palmisano's  re-election  and,  of  course.  Stormy 
Johnson,  kept  Louisiana  in  the  forefront  in  organized 
medicine.  You  would  have  been  very  proud  of  these  Loui- 
siana physicians  and  the  entire  Louisiana  AMA  Delega- 
tion as  well.  You  may  have  chuckled  to  see  doctors  from 
all  over  the  United  States  clamoring  to  taste  gumbo  with 
a few  drops  of  Tabasco.  The  AMA  meeting  made  us  real- 
ize more  than  ever  the  challenges  ahead. 

So  as  we  enter  the  21st  century,  I think  the  words  of 
Goethe  ring  true  as  he  said,  "I  find  the  great  thing  in  this 
world  is  not  so  much  where  we  stand  as  in  what  direc- 
tion we  are  moving."  And  where  will  the  LSMS  head  at 
the  beginning  of  the  new  century? 

First  of  all,  we  will  need  to  follow  the  Policies  of  the 
House  of  Delegates  Manual.  We  must  represent  as  many 
physicians  as  possible,  speaking  as  one  voice,  having  our 
differences  ironed  out  privately,  always  cognizant  of  lis- 
tening to  our  colleagues.  We  will  have  differences  which 
some  want  to  exploit  to  divide  us  in  areas  such  as  aca- 
demics, primary  care,  family  care,  surgical  specialties, 
psychiatry,  or  the  treatment  of  certain  organ  systems  or 
diseases.  Always  remember  we  have  intensely  studied 
the  body  structure,  how  it  works  and  interacts,  far  more 
than  any  other  group.  We  must  keep  in  mind  that  we 
have  far  more  in  common  than  we  have  differences. 

Our  unity  must  be  maintained  as  a mindset  requir- 
ing constant  effort  to  keep  communications  open  among 
different  ethnic  groups,  minorities,  women,  and  forms  of 
practice.  We  will  represent  solo  and  small  specialty 
groups,  as  well  as  multi-specialty  groups.  We  must 
strengthen  our  committee  of  statewide  specialty  officers. 
It  is  important,  also,  to  prepare  ways  for  the  LSMS  to  rep- 
resent physicians  employed  by  large  institutions,  inform- 
ing these  doctors  of  what  the  LSMS  does  for  them  and  at 
the  same  time  listening  to  how  these  doctors  think  we 
could  be  more  helpful  to  them,  always  keeping  in  mind 
that  we  are  all  physicians. 

Everyone  here  makes  contact  with  colleagues  every 
working  day  in  doctors7  lounges  or  in  cafeterias.  It  is  ben- 
eficial for  all  LSMS  members  to  listen  to  others  and  to 
relay  ideas  both  constructive  and  critical.  These  comments 
only  make  us  stronger.  And  these  ideas  should  be  per- 
ceived as  valid  and  should  be  addressed  at  least  by  the 
officers.  I intend  to  travel  about  the  state  to  listen  to  com- 
ponent societies'  suggestions  and  to  convey  the  concern 
of  the  LSMS  for  what  everyone  has  to  say. 

We  need  to  increase  our  membership  in  order  to  have 
the  reasources  to  do  the  job  that  needs  to  be  done.  In- 
formed current  members  who  believe  in  what  we  are  try- 
ing to  accomplish  are  the  best  ones  to  enroll  new  mem- 
bers. After  several  years  of  trying,  we  can  now  provide 


lists  of  who  is  licensed  to  practice  in  each  component  so- 
ciety area  and  identify  potiental  new  members.  One-on- 
one  recruiting  is  the  most  successful,  but  this  requires 
volunteer  effort.  Those  who  will  help  can  be  assisted  by 
the  Membership  Committee  and  the  LSMS  staff. 

Physicians  are  the  best  source,  also,  of  ideas  and  in- 
formation pertaining  to  what  is  in  our  patients'  best  in- 
terests. We  need  to  increase  our  involvement  in  consumer 
and  employee  organizations.  In  our  current  system,  em- 
ployers purchase  a major  part  of  health  insurance.  On 
October  4th,  CNN  stated  that  44  million  Americans  are 
without  health  insurance.  We  can,  and  I think  should, 
advocate  federal  legislative  change  to  permit  individual 
deductions  of  health  insurance  premiums.  Our  voices  will 
need  to  be  heard  even  more  loudly  than  in  the  past  in 
order  to  help  educate  our  patients  as  to  essential  features 
of  individual  policies,  including  what  their  families  need 
as  well.  Our  Insurance  Committee  should  have  a role  in 
this  endeavor. 


Dr.  Lowentritt  and  Dr.  Lewis  during  inaugural  ceremonies. 

This  brings  us  to  the  area  of  political  representation. 
If  the  amendment  passes  tomorrow  to  open  up  the  Fiscal 
Louisiana  Legislative  Session,  we  will  face  annual  battles, 
including  next  year  with  challenges  to  expanded  practice 
from  other  health  care  providers  seeking  privileges  by 
legislation.  This  will  require  constant  vigilance,  constant 
contact  with  our  legislators  by  each  of  us.  We  have  a su- 
perb Office  of  Governmental  Affairs  and  Council  on  Leg- 
islation who  can  teach  all  of  us  the  best  one-on-one  ap- 
proach with  officials.  We  will  find  effective  ways  of  gen- 
erating grass  roots  support,  also,  by  involving  our  superb 
medical  society  alliance  as  another  major  player. 


Supplement  78  VOL  152  March  2000  J La  State  Med  Soc 


The  fight  to  defend  the  professional  liability  cap,  on 
both  judicial  and  legislative  levels,  will  be  our 
responsiblity.  We  must  inform  those  involved  of  the  fact 
that  this  cap  is  a factor  in  providing  affordable  and  avail- 
able health  care  within  reach  of  our  patients.  The  cap  for 
most  of  us  saves  more  on  liability  premiums  than  the 
medical  society  dues  cost  us.  This  highlights  an  area  where 
the  LSMS  has  achieved  a great  deal  on  our  behalf  over 
the  years. 

LAMP  AC  is  vitally  important.  For  some  it  opens  the 
door.  We  need  to  give  more! 

We  continue  to  face  declining  reimbursements  and 
managed  care  intrusions  driven  by  a bottom  line  search 
for  profits.  Our  medical  society  must  do  what  we  can  to 
assist  our  members  and  patients.  Our  Managed  Care 
Liason  Committee  constantly  explores  both  developing 
problems  and  searches  for  solutions. 

Medicaid  is  an  area  where  state  actions  are  possible. 
We  will  monitor  proposals  to  privitize  portions.  We  need 
to  do  what  we  can  by  skillful,  prudent  lobbying  to  obtain 
a fair  share  of  the  tobacco  money  argued  because  of  long- 
term health  care  expenses.  Every  interest  group  wants  a 
part  of  what  is  seen  as  a windfall. 

And  Medicare  will  also  remain  an  area  of  concern. 
This  is  largely  a federal  effort,  and  thus  we  must  work 
through  the  AMA. 

The  21st  century  has  been  referred  to  as  'The  Biotech 
Century" . During  this  century,  genetic  engineering  has 
the  potential  to  conquer  cancer,  grow  new  blood  vessels 
in  tumors,  create  new  organs  from  stem  cells,  and  per- 
haps even  rest  the  primevial  genetic  coding  that  causes 
cells  to  age. 

These  are  exciting  times  in  which  to  practice  medi- 
cine. And  they  are  as  challenging  and  demanding  as  they 
are  enlightening.  Physicians  in  Louisiana  must  be  ready 
to  meet  these  opportunities  head-on. 

An  article  in  Time  magazine  in  October  1998  noted 
that  every  day  in  one  major  medical  center,  approximately 
5,000  beepers  chirp  or  vibrate,  relaying  12,000  messages. 
And  the  same  hospital  pharmacy  dispenses  some  7,000 
doses  of  various  medications  daily  for  hospital  patients. 
Our  personal  practice  situations  are  probably  nothing  like 
this,  but  they  are  nevertheless  busier  than  many  other 
professions. 

We  as  physicians  are  probably  in  the  most  grueling, 
rewarding,  and  meaningful  profession  overall  in  the 
world.  Someone  or  something  ignited  the  desire  in  us  to 
want  to  help  patients.  Let  us  be  proud  that  we  made  the 
decision  to  study  medicine,  that  we  are  able  to  make  a 
difference  in  the  lives  of  others. 

So  what  will  the  year  2000  mean  to  us  in  terms  of 
medicine  in  Lousiana?  What  can  we  do  in  this  exciting 
millennium  to  help  medicine? 

As  members  of  the  medical  profession,  let's  work 
hard  together,  joining  our  multiple  talents  to  help  make 


LSMS  projects  achieve  the  best  possible  care  for  our  pa- 
tients and  the  people  in  Louisiana.  We  can  accomplish 
more  as  a group  than  we  can  as  individuals.  Let's  get  in- 
volved and  stay  involved. 

As  a Louisiana  physician,  I ask  each  of  you  to  apply 
the  same  hard  work,  talent,  and  intelligence  to  LSMS 
projects  you  have  exhibited  so  many  times  in  the  past. 
We  have  the  expertise  and  wisdom  of  outstanding  past 
presidents,  officers,  and  committee  chairmen  to  guide  us. 
And  our  medical  society  staff  is  one  of  the  best  in  the  coun- 
try. 

It  is  important  that  we  face  the  issues  affecting  Loui- 
siana squarely;  that  we  become  more  involved  in  LSMS; 
that  our  enthusiasms  become  contagious  and  thus  involve 
more  members  of  our  various  societies.  We  all  need  to 
make  LSMS  programs  and  projects  our  "own"  and  be- 
come part  of  the  planning  and  the  successes. 

Let's  move  in  the  direction  of  better  health  care  for 
all  the  citizens  of  this  great  state  of  Louisiana.  Together 
we  can  make  Louisiana  medicine  better  than  it  was  yes- 
terday so  that  tomorrow  our  patients  will  reap  the  ben- 
efits of  the  best  care  we  can  possibly  provide. 


Supplement  79  VOL  152  March  2000  J La  State  Med  Soc 


1999  Delegates 


The  following  is  a list  of  the  delegates  and  alternate  delegates  who  attended  the  120th  LSMS  Annual 
Meeting  in  Baton  Rouge,  Louisiana,  October,  1999. 


James  B.  Aiken,  MD 
Merlin  H.  Allen,  MD 
James  M.  Anderson,  MD 
Russell  Lee  Anderson,  MD 
Paul  Azar,  Jr.,  MD 
James  K.  Baker,  MD 
Drew  Baldwin 
Cecil  N.  Bankston,  Jr.,  MD 
David  L.  Barnes,  MD 
J.  Robert  Barnes,  MD 
Donnie  Batie,  MD 
Carol  Bayer,  MD 
Charles  D.  Belleau,  MD 
Terence  Beven,  MD 
Stanley  Bienasz,  MD 
Irving  Blatt,  MD 
Joan  Blondin,  MD 
Robert  Borders,  MD 
R.  Graham  Boyce,  MD 
Lawrence  L.  Braud,  MD 
Patrick  Breaux,  MD 
Joseph  M.  Brenner,  MD 
Emile  Broussard,  MD 
Kenneth  Brown,  MD 
Steve  Bujenovic,  MD 
Floyd  A.  Buras,  Jr.,  MD 
Joseph  D.  Busby,  Jr.,  MD 
Thomas  Campanella,  MD 
Sean  T.  Canale,  MD 
Robert  T.  Casanova,  Jr.,  MD 
Elwyn  Cavin,  MD 
Robert  V.  Cazayoux,  Jr.,  MD 


Milton  Chapman,  MD 
Robert  J.  Chugden,  MD 
Roderick  V.  Clark,  MD 
H.  Jay  Collins  worth,  MD 
James  Conway,  MD 
James  R.  Corcoran,  MD 
Shirley  S.  Covington,  MD 
Lawson  G.  Cox,  MD 
Vincent  A.  Culotta,  Jr.,  MD 
Joan  Curtis,  MD 
Candace  Cutrone,  MD 
Renee  C.  Daigle,  MD 
William  Daly,  Jr,  MD 
Walter  Daniels,  MD 
Pamela  S.  Darr,  MD 
Robert  E.  Dawson,  MD 
David  A.  Depp,  MD 
Keith  F.  DeSonier,  MD 
Robert  L.  DiBenedetto,  MD 
Richard  P.  Dickey,  MD 
William  Dimattia,  MD 
Sarat  K.  Donepudi,  MD 
Donald  W.  Doucet,  MD 
Hosea  J.  Doucet,  III,  MD 
Heber  Dunaway,  Jr.,  MD 
Wallace  H.  Dunlap,  MD 
James  S.  Dunnick,  MD 
Daniel  G.  Dupree,  MD 
Michael  S.  Ellis,  MD 
Jeanne  M.  Estes,  MD 
Robert  C.  Ewing,  MD 
K.  Barton  Farris,  MD 


Supplement  80  VOL  152  March  2000  J La  State  Med  Soc 


Daniel  Ferguson,  MD 
Thomas  Fields,  Jr.,  MD 
Mary  Jo  Fitz-Gerald,  MD 
Juliana  Fort,  MD 
David  G.  Founder,  MD 
Craig  J.  Frederick,  MD 
Paul  Fuselier,  MD 
Linda  Gage-White,  MD 
Geoffrey  W.  Garrett,  MD 
Henry  F.M.  Garrett,  MD 
Juan  J.  Gershanik,  MD 
Amy  M.  Givler,  MD 
Donald  N.  Givler,  Jr.,  MD 
John  A.  Gonzalez,  MD 
Stewart  T.  Gordon,  MD 
James  E.  Grace,  MD 
Warren  D.  Grafton,  MD 
Wayne  Gravois,  MD 
Matthew  R.  Green,  Jr.,  MD 
Hilliard  M.  Haik,  Jr.,  MD 
William  T.  Hall,  MD 
Donald  Hammett,  MD 
Alfred  W.  Hathom,  Jr.,  MD 
Corey  J.  Hebert,  MD 
Stephen  Heilman,  MD 
Lynn  E.  Hickman,  MD 
Janet  B.  Higgins,  MD 
R.  Kelly  Hill,  Jr.,  MD 
Samuel  Holladay,  Jr.,  MD 
Stanley  Hoover,  MD 
David  R.  Hunter,  MD 
Harold  L.  Ishler,  Jr.,  MD 
Trenton  L.  James,  II,  MD 
Jay  Jhunjhunwala,  MD 
Daniel  H.  Johnson,  Jr.,  MD 
Rodney  Jung,  MD 
Robert  M.  Kessler,  MD 
Russell  C.  Klein,  MD 
Evelyn  Kluka,  MD 
Patrick  R.  Krake,  MD 


Steven  Kraus,  MD 
Michael  L.  Kudla,  MD 
William  S.  J.  LaCorte,  MD 
Maximo  Lamarche,  MD 
Barry  G.  Landry,  MD 
Richard  Lastrapes,  MD 
Christopher  L.  Lee,  MD 
Owen  B.  Leftwich,  MD 
John  E.  Lemoine,  MD 
C.  Clinton  Lewis,  MD 
Dolleen  Licciardi,  MD 
James  Lip  state,  MD 
William  Long,  MD 
Joshua  Lowentritt,  MD 
Leo  L.  Lowentritt,  Jr.,  MD 
F.  Brobson  Lutz,  Jr.,  MD 
William  E.  Lyles,  MD 
Cris  Mandry,  Jr.,  MD 
Jerrell  Mathison,  MD 
Ralph  Maxwell,  III,  MD 
Catherine  McCormick,  MD 
Joseph  T.  Miceli,  MD 
Clifton  T.  Morris,  Jr.,  MD 
Dennis  W.  Nave,  MD 
Harold  Neitzschman,  III,  MD 
Cherie  Niles,  MD 
Henry  Dupont  Olinde,  MD 
Robert  Osborne,  MD 
Alan  J.  Ostrowe,  MD 
Richard  J.  Paddock,  MD 
Richard  G.  Palfrey,  MD 
Donald  Palmisano,  MD 
Brooke  S.  Parish,  MD 
Kenneth  S.  Parks,  MD 
Pamela  A.  Parra,  MD 
Sandeep  A.  Patel,  MD 
Gary  Q.  Peck,  MD 
Gordon  Peek,  MD 
Marcus  L.  Pittman,  EH,  MD 
James  Ralston,  MD 


Supplement  81  VOL  152  March  2000  J La  State  Med  Soc 


Aretta  J.  Rathmell,  MD 
Therese  Louise  Ritter,  MD 
Kenneth  Roberts,  DO 
Alan  M.  Robson,  MD 
Eduardo  E.  Rodriguez,  MD 
Robert  W.  Romero,  MD 
A.  Kenison  Roy,  III,  MD 
Reuben  S.  Roy,  Jr.,  MD 
Vincent  Robert  Russo,  MD 
Joseph  A.  Sabatier,  Jr.,  MD 
Charles  V.  Sanders,  Jr.,  MD 
Robert  M.  Sayes,  MD 
Donald  A.  Schexnayder,  MD 
William  Schumacher,  MD 
James  M.  Schweitzer,  MD 
Jay  Shames,  MD 
Irvin  Sherman,  Jr.,  MD 
Bryan  G.  Sibley,  MD 
Roger  D.  Smith,  MD 
Eli  Sorkow,  MD 
Eugene  C.  St  Martin,  MD 
Melville  J.  Sternberg,  MD 
Adrien  Stewart,  MD 
Charles  Stewart,  MD 
Dudley  M.  Stewart,  Jr.,  MD 
Gilbert  Stock,  Jr.,  MD 
Theodore  Strickland,  MD 
Paul  Stringfellow,  MD 
Mohammad  Suleman,  MD 
Martin  Tanner,  MD 
Victor  E.  Tedesco,  IV,  MD 
Wallace  Tomlinson,  MD 
Louis  Trachtman,  MD 
David  C.  Treen,  MD 
Lynn  Z.  Tucker,  MD 
Joseph  F.  Uddo,  Jr.,  MD 
John  S.  Van  Hoose,  MD 
James  W.  Vildibill,  Jr.,  MD 
Nicholas  J.  Viviano,  MD 
Ted  B.  Warren,  MD 
W.  Juan  Watkins,  MD 


Larry  D.  Weiss,  MD 
Frederick  J.  White,  III,  MD 
Randall  White,  MD 
R.  Mark  Williams,  MD 
R.  Bruce  Williams,  MD 
Susan  V.  Williams,  MD 
James  W.  Wilson,  MD 
Rodney  Wise,  MD 
Barbara  T.  Wizer,  MD 
Eugene  F.  Worthen,  MD 
William  D.  Zeichner,  MD 
Mark  H.  Zielinski,  MD 


Supplement  82  VOL  152  March  2000  J La  State  Med  Soc 


Executive  Department 

Dave  Tarver  • Executive  Vice  President 
Geraldine  Leche  • Executive  Assistant 

Phone:  (225)  763-2320  • FAX:  (225)  763-6122 

Administration 
Jeanette  Harmon  • Director 
Toni  Smith  • Medical  Education  Coordinator 
Bonna  White  • Copy  Specialist 

Phone:  (225)  763-2319  • FAX:  (225)  763-6122 

Governmental  Affairs 
Sharon  Knight  • Director 
Kerry  L.  Cooley  • Assistant  Director 
David  L.  Kemmerly  • Associate  Director 
Janet  Anderson  • Legislative  Assistant 
Mary  DuCote  • Administrative  Assistant 

Phone:  (225)  763-2323  • FAX:  (225)  763-9881 

Legal  Affairs 

Amy  W.  Phillips  • Director  and  General  Counsel 
Ragan  Cannella  • Administrative  Assistant 

Phone:  (225)  763-2312  • FAX:  (225)  763-2335 

Membership  & Finance 

Bryan  LaHaye  • Director 
Dora  Fonti  • Membership  Coordinator 
Leigh  Arnette  • Membership  Services  Representative 
Irene  Walz  • Bookkeeper 

Phone:  (225)  763-2302  • FAX:  (225)  763-2333 

Public  Affairs 

Cathy  Lewis  • Director 
Candace  Davis  • Publications  Coordinator 
Melissa  Cantrell  • Administrative  Assistant 

Phone:  (225)  763-2310  • FAX:  (225)  763-2332 

Physicians’  Health  Foundation  of  Louisiana 

Michael  R,  DeCaire  • Administrative  Director 

Dr.  Martha  E.  Brown  • Medical  Director 
Phone:  (225)  763-8500  • FAX:  (225)  763-2333 


Supplement  83  VOL  152  March  2000  J La  State  Med  Soc 


1999  Annual  Report 

is  a publication  of: 

Louisiana  State  Medical  Society 

6767  Perkins  Road 
Baton  Rouge,  LA  70808 
Phone:  225-763-8500 
Fax:  225-763-2332 
publicaffairs@lsms.org 


day.  It  was  stimulated  in  its  potency  of 
contagion  by  the  large  importation  of  negro 
slaves  from  Africa  during  the  time  of  slavery. 

" After  the  period  of  the  Crusades,  smallpox 
became  widely  spread  all  over  Europe  and 
rapidly  became  the  greatest  scourge  that 
humanity  had  to  contend  with.  It  decimated 
large  regions  of  country  and  depopulated  and 
impoverished  others.  All  methods  and  all 
theories  were  tried  to  check  this  dreaded 
invasion,  but  they  came  to  naught,  and  the 
ravager  kept  on  its  course  of  death  and 
destruction.  It  was  more  feared  than  the  plague. 
The  Wandering  Jew  by  Eugene  Sue,  though  it 
gives  in  a masterful  way  the  fear  and  panic  it 
brought  to  all  minds,  still  conveys  but  a faint 
idea  of  its  terrors.  The  salves  and  sweating 
processes  introduced  by  the  Eastern  physicians, 
Arabian  and  others,  were  abandoned  about  the 
beginning  of  the  seventeenth  century  for  the 
sensible  antiphlogistic  treatment  suggested  by 
the  celebrated  Sydenham.  Still,  in  spite  of  this, 
the  ravages  kept  on,  and  mankind  was  the  prey 
to  its  merciless  inroads,  and  scarcely  a decade 
elapsed  that  the  victims  were  not  counted  by 
thousands,  and  tens  of  thousands.  Many  plans 
and  procedures  were  tried  but  all  to  no  avail. 
In  the  time  of  King  Edward  II,  his  son  Prince 
John  was  treated  by  being  placed  in  bed  with 
red  curtains  around  it.  He  was  covered  with 
red  blankets,  and  he  was  made  to  suck  the  juice 
of  red  pomegranate  and  to  gargle  his  throat 
with  red  mulberry  wine.  About  this  time,  in 
opposition  to  the  belief  that  the  aged  or  those 
above  60  years  of  age  were  less  subject  to 
variola,  we  have  the  notable  historic  fact  of  the 
death  of  Louis  XV  of  France,  who  contracted 
the  disease  from  a child  who  had  scarcely 
reached  the  age  of  puberty  and  who  had  been 
brought  to  his  lascivious,  shameless,  and 
corrupt  being.  At  about  the  seventeenth  and 
eighteenth  centuries,  7%  to  9%  of  all  deaths 
were  due  to  smallpox.  From  1783  to  1797,  one- 
twelfth  of  the  total  mortality  of  Berlin  was  of 
variola.  During  the  eighteenth  century,  there 
were  30  thousand  deaths  in  France  actually  due 
to  it.  Vonjunker  states,  in  the  Archiv  dev  Aerzte 


and  Sellsorger  wieder  die  Pockenothe,  of  the  year 
1796  — the  very  year  that  Edward  Kenner 
finished  his  final  experiment  on  the  cow-pox  — 
that  26,846  inhabitants  of  Prussia  died  that  year 
with  this  disease  out  of  a population  of  seven 
million  inhabitants.  The  first  step  in  the  direction 
of  prophylaxis  was  made  by  the  process  of 
inoculation  in  the  seventeenth  century.  This 
method  might  be  better  called  variolization  and 
it  was  practiced  in  China  and  India  before  that 
time,  only  we  have  no  perfect  record  of  its  first 
trial.  It  was  positively  performed  in  Constan- 
tinople in  1673  and  for  a long  time  afterwards, 
principally  on  young  children  after  their  physical 
condition  had  been  prepared  by  a system  of 
dieting  and  laxatives.  It  was  in  1717  that  Lady 
Wortley  Montagu  heard  of  this  method  while  in 
Constantinople  and  inoculated  her  son  with  the 
smallpox  virus.  Four  years  later,  when  she 
returned  to  England,  she  also  inoculated  her 
daughter  successfully.  Though  this  met  with 
opposition  from  the  legitimate  profession,  it 
became  widely  popular,  and  even  in  this  country 
up  to  1845,  I can  certify  that  inoculation  was 
performed  by  many  English  surgeons,  as  I have 
this  illustration  of  it  in  my  own  family.  A 
grandparent  of  my  wife,  an  English  army 
surgeon,  retired  in  Montreal,  inoculated  all  his 
children  before  they  were  two  or  three  years  of 
age.  None  of  them  ever  had  more  than  two  or 
three  slight  pitting  marks  and  were  only  very 
slightly  ill.  He  prepared  them  thoroughly  for  the 
process  and  never  lost  any  patients  by  it.  Still, 
this  was  only  a crude  method  and  laid  the 
operator  liable  to  fearful  risks,  because  even  if 
there  was  only  a minimum  danger  to  the  patient, 
the  person  inoculated  could  easily  infect  those 
around  him.  Laws  were  promulgated  against  the 
performance  of  inoculation.  It  was  only  at  the 
end  of  the  eighteenth  century,  in  1796,  that 
Edward  Jenner  came  with  his  great  discovery  to 
allay  the  fear  and  horror  of  this  terrible  scourge. 
His  discovery  certainly  opened  a new  era  in  the 
line  of  preventive  medicine.  It  was  the  "open 
sesame"  of  serum  therapy.  Today,  the  mortality 
from  smallpox  is,  I believe,  only  one  in  2377 
inhabitants,  when  before  it  was  in  many 


J La  State  Med  Soc  VOL  152  March  2000  117 


countries  one  to  every  ten  deaths  that  occurred. 
Statisticians  also  claim  that  the  average  of  life 
has  been  increased  two  to  three  years  more  than 
it  was  formerly  And  finally,  in  the  mere  fact  of 
blindness,  the  diminution  since  the  practice  of 
vaccination  has  been  fully  one-fourth. 

"Let  us  make  a rapid  calculation  of  the 
financial  benefit  to  the  world  of  such  a saving 
of  human  life.  When  we  think  of  the  loss  in  time 
and  money,  of  sickness,  suffering,  and  death, 
we  can  appreciate  the  great  benefit  of  this 
gigantic  discovery. 

"Vaccination  is  compulsory  in  Bavaria, 
Sweden,  Scotland,  England  and  Germany.  In 
France  and  America,  it  became  compulsory  only 
in  the  schools  and  some  of  the  departments  of 
the  government.  Vaccination  or  the  process  of 
giving  cowpox,  or  vaccinia  to  human  beings  to 
protect  them  from  variola,  may  be  well 
considered  to  have  been  established  with  the 
discoveries  and  researches  of  Edward  Jenner  in 


1796.  It  is  true  that  the  ancients  tell  us  that  there 
was  a method  in  vogue  in  India  and  ancient 
Persia  by  which  men  were  protected  from 
smallpox,  but  as  this  method  was  never  properly 
explained,  and  as  it  was  not  handed  to  us  in  any 
way  that  we  could  use  it  practically,  it  was 
useless  to  us.  Of  course,  this  method  must  have 
been  a process  of  variolization  or  inoculation, 
as  we  have  accurate  record  of  its  being  practiced 
in  Constantinople  since  1673.  But  it  was  not 
before  the  time  of  Edward  Jenner,  on  the  Plains 
of  Berkley,  that  this  learned  scientist, 
experimenting  between  the  years  1775  to  1798, 
was  able  with  incontestable  facts  to  establish  the 
preserving  power  of  the  virus  of  cowpox  against 
variola  when  inoculated  properly  in  human 
beings.  It  was  certainly  one  of  the  greatest 
discoveries  of  that  period,  and  will  forever  mark 
that  period  as  the  opening  age  of  enlightenment 
in  the  field  of  progressive  medicine." 


Dr  Colon  has  a plastic  surgery  practice  in 
Metairie , Louisiana  and  has  lectured  on  history  of  medicine 
at  Louisiana  State  University  Health  Services  Center  and 
Tulane  University  School  of  Medicine, 
both  in  New  Orleans,  Louisiana. 


118  J La  State  Med  Soc  VOL  152  March  2000 


Partial  Colectomy  Required  for  Resection 
of  Renal  Cell  Carcinoma: 

A Case  Report  and  Review  of  Treatment 

Options  for  Locally  Advanced  Disease 

Karen  L.  Crotty,  MD  and  Joseph  N.  Macaluso  Jr,  MD 


Because  it  is  more  commonly  discovered  as  a result  of  an  incidental  finding  on  radiologic 
studies,  renal  cell  carcinoma  is  being  diagnosed  at  earlier  stages.  Patients  still,  however,  present 
occasionally  with  locally  advanced  disease.  Such  a case  is  presented  in  a patient  who  required 
a partial  colectomy  at  the  time  of  radical  nephrectomy  to  remove  all  of  his  disease.  Also 
reviewed  is  the  current  state  of  treatment  options  available  for  renal  cell  carcinoma,  including 
chemotherapy,  radiation  therapy,  immunotherapy,  and  surgery.  Despite  advances  in  some  of 
these  areas,  the  mainstay  of  treatment  for  locally  advanced  renal  cell  carcinoma  remains 
surgery. 


For  many  years,  over  50%  of  patients 
diagnosed  with  renal  cell  carcinoma 
(RCC)  had  metastatic  disease  at  the  time 
of  presentation.  This  has  now  decreased  to  30%, 
most  likely  because  renal  masses  are  now  being 
diagnosed  when  discovered  as  incidental  find- 
ings on  studies  such  as  ultrasound  or  CT  scan 
done  to  evaluate  other  medical  conditions.12 
Occasionally,  however,  tumors  still  present  with 
locally  advanced  disease  without  evidence  of 
metastatic  disease.  Such  a case  is  presented  be- 
low, along  with  a review  of  treatment  options 
available  for  the  treatment  of  locally  advanced 
disease. 


CASE  REPORT 

A 67-year-old  white  man  with  no  chronic 
medical  illnesses  noticed  a right  lower  quadrant 
mass  during  an  evaluation  for  new  onset 
dysphagia.  A CT  scan  showed  an  11  by  11  cm 
mass  involving  the  lower  pole  of  the  right 
kidney.  The  mass  was  inhomogeneous  and 
extended  18  cm  interiorly  into  the  pelvis.  In  some 
views,  the  plane  between  the  mass  and  the  psoas 
muscle  was  obscured  suggesting  invasion.  There 
was  no  evidence  of  lymphadenopathy  or  other 
metastatic  disease.  The  remainder  of  the 
metastatic  evaluation,  including  liver  function 


J La  State  Med  Soc  VOL  152  March  2000  119 


tests,  alkaline  phosphatase,  and  CT  scan  of  the 
chest,  was  negative. 

At  the  time  of  exploratory  laparotomy,  the 
mass  was  found  to  originate  from  the  right 
kidney  and  appeared  to  involve  the  posterior 
peritoneum.  However,  the  mass  did  not  appear 
to  involve  the  underlying  muscle.  Anteriorly,  the 
ascending  colon  was  fixed  to  the  surface  of  the 
tumor.  Inspection  of  the  remainder  of  the 
abdomen  revealed  no  evidence  of  metastatic 
disease.  After  attempts  to  dissect  the  colon  away 
from  the  mass  were  unsuccessful,  the  decision 
was  made  to  resect  the  adherent  section  of  bowel 
to  obtain  access  to  the  renal  hilum. 
Approximately  20  cm  of  colon  was  resected  and 
left  attached  to  the  tumor.  A right  radical 
nephrectomy  was  then  performed.  Posteriorly, 
the  tumor  invaded  the  peritoneum  with  a few 
small,  satellite  implants,  but  this  was  all 
removed,  and  at  the  completion  of  the  resection, 
no  visible  tumor  remained.  A side-to-side  ileo- 
colonic anastomosis  was  then  performed.  The 
patient  had  an  unremarkable  post-operative 
course  and  was  discharged  on  post-op  day  5. 

The  pathology  showed  renal  cell  carcinoma 
(RCC)  with  extensive  penetration  of  the  renal 
capsule  and  perirenal  fat  and  peritoneum. 
Histologically,  there  were  varying  patterns  of 
RCC,  ranging  from  well-differentiated  papillary 
adenocarcinoma  to  clear  cell  carcinoma  to 
anaplastic  and  pseudosarcomatous  patterns. 
There  was  invasion  of  the  serosa  of  the  colon, 
but  no  involvement  of  the  mucosa  was  seen. 

DISCUSSION 

Despite  medical  advances  in  the  last  quarter  of 
a century,  renal  cell  carcinoma  remains  a 
problematic  malignancy,  being  a fairly 
radioresistant  and  chemoresistant  tumor. 
Effective  therapy  has  been,  and  remains, 
surgical.  Five-year  survival  after  radical 
nephrectomy  for  tumors  confined  to  Gerota's 
fascia  is  approximately  60%  to  80%.  When  tumor 
extends  beyond  Gerota's  fascia  into  the  perirenal 
tissues,  but  does  not  directly  invade  adjacent 
organs,  the  5-year  survival  approaches  45% 
when  all  tumor  is  excised.3  At  times,  this  may 


necessitate  resection  of  surrounding  organs  or 
tumor  thrombus  extending  into  the  inferior  vena 
cava  and  even  the  right  atrium.4  The  importance 
of  total  excision  of  tumor  is  emphasized  by  a 
study  that  showed  that  patients  with  locally 
advanced  disease  and  incomplete  resection  have 
a significantly  poorer  prognosis  than  patients 
with  distant  metastases.5  In  this  review  of 
patients  with  metastatic  RCC,  of  those  patients 
in  whom  the  primary  tumor  was  not  completely 
excised,  only  20%  survived  6 months  and  none 
survived  1 year. 

As  mentioned,  other  modalities  of  treatment 
have  had  little  benefit  in  the  treatment  of  RCC, 
especially  with  regard  to  metastatic  disease. 
There  have  been  reports  of  spontaneous 
regression  of  metastatic  disease  after 
nephrectomy;  however,  large  studies  have 
shown  the  incidence  to  be  less  than  1%,6  thus 
exposing  a patient  with  widely  metastatic 
disease  to  the  morbidity  of  the  surgery  without 
any  real  probability  of  a benefit. 

Chemotherapy  has  shown  little  effective- 
ness, either  against  a primary  tumor  or  meta- 
static disease.  While  one  study  showed  a 25% 
objective  response  rate  with  Vinblastine,7  a sum- 
mary of  39  chemotherapeutic  regimens,  using 
either  single  agents  or  combination  therapy, 
found  only  an  8%  complete  plus  partial  re- 
sponse, usually  of  short  duration.8 

Because  of  responsiveness  in  some  animal 
models  of  RCC,  hormonal  therapy  using  proges- 
tational agents  has  been  used  in  the  past.  Re- 
ports of  objective  responses  have  varied  from 
0%  to  15%.9  There  is  minimal  toxicity  associated 
with  the  use  of  these  agents,  including  such 
symptoms  as  nausea,  fluid  retention,  and  breast 
tenderness.  Since  no  other  effective  therapy  ex- 
ists outside  of  immunotherapy  centers  conduct- 
ing clinical  trials,  hormonal  therapy  is  occasion- 
ally still  used  today,  however  with  little  objec- 
tive proof  of  efficacy. 

Radiation  therapy  (RT)  has  at  present  a 
limited  role  in  the  treatment  of  RCC.  It  is  useful 
in  treating  symptomatic  metastatic  bone  lesions, 
but  the  dosage  required  to  treat  a primary  lesion 
in  the  renal  fossa  is  too  toxic  for  surrounding 


120  J La  State  Med  Soc  VOL  152  March  2000 


organs.  RT  given  preoperatively  to  large  tumors 
has  not  consistently  been  shown  to  increase 
survival.  Using  post-operative  RT  to  sterilize  a 
field  with  known  residual  disease,  positive 
surgical  margins,  or  patients  at  risk  for  local 
recurrence  after  nephrectomy  is  an  appealing 
idea.  However,  a prospective  randomized  study 
by  Finney10  actually  showed  a poorer  survival 
in  those  patients  receiving  RT.  The  local 
recurrence  rate  between  the  two  groups  was 
found  to  be  identical.  A more  recent  retro- 
spective, case-controlled  study11  examined  the 
effect  of  post-operative  RT  in  the  era  of  CT  scans 
being  used  to  configure  treatment  portals.  This 
study  showed  that  none  of  the  patients  who 
received  post-operative  RT  had  local  regional 
recurrence  despite  the  finding  of  positive 
surgical  margins  in  42%.  This  zero  rate  of  local 
recurrence  was  compared  to  a 30%  incidence  in 
the  case-control  group.  The  5-year  disease-free 
survival  in  the  RT  group  was  75%  but  only  62% 
in  those  without  postoperative  RT.  These 
findings  need  to  be  confirmed,  however,  in  a 
randomized,  prospective  study. 

The  most  recent  area  of  work  in  the  treatment 
of  advanced  RCC  is  with  immunotherapy,  using 
biologically  active  agents  to  stimulate  the  host's 
immune  system.  Alpha-interferon  (a-IFN)  is  a 
substance  involved  in  stimulating  the  immune 
system  into  anti-viral  and  anti-proliferative 
states.  Initial  studies  showed  a 41%  objective 
response  rate.  However,  on  follow-up  phase  II 
studies,  there  was  only  a 1%  complete  response 
and  a 15%  to  20%  partial  response  rate.  The 
responders  to  a-IFN  therapy  were  found  to  be 
those  patients  who  had  already  undergone 
nephrectomy,  had  good  performance  status,  had 
mostly  pulmonary  metastatic  disease  burden, 
and  had  a long  disease-free  interval  before 
development  of  metastatic  disease.12 

Interleukin-2  (IL-2)  is  a T-cell  growth  factor 
which  has  been  shown  to  generate  lymphokine- 
activated  killer  (LAK)  cells,  enhance  natural 
killer  (NK)  cell  function,  and  stimulate  the 
growth  of  T-cells  with  anti-tumor  activity.  IL-2 
has  been  used  with  and  without  infusions  of 
LAK  cells  for  the  treatment  of  RCC.  The  overall 


response  rate  in  a phase  II  clinical  trial  of  IL-2 
with  LAK  cells  was  16%  compared  to  a response 
rate  of  33%  seen  in  a National  Cancer  Institute 
study  with  the  same  agents.  In  this  phase  II 
study,  2 of  the  3 patients  with  partial  responses 
required  surgery  to  be  rendered  disease-free. 
When  the  authors  combined  the  results  from 
numerous  studies,  it  was  found  that  the  objec- 
tive response  rate  for  patients  with  pulmonary 
disease  only  was  38%,  but  those  patients  with 
residual  disease  in  the  abdomen  had  a 20%  re- 
sponse rate.13  The  toxicity  of  IL-2  therapy  is  sig- 
nificant. However,  its  side  effects  include  hy- 
potension, oliguria,  peripheral  and  pulmonary 
edema,  CNS  dysfunction,  and  respiratory  dis- 
tress. These  effects  are  usually  reversible  with 
cessation  of  therapy,  and  the  mortality  is  less 
than  2%. 12 

An  area  of  current  debate  is  whether  a ne- 
phrectomy should  be  performed  prior  to  the 
administration  of  immunotherapy.  While  immu- 
notherapy is  less  effective  with  the  primary  tu- 
mor in  place,  experience  has  shown  that  nephre- 
ctomy in  the  face  of  metastatic  disease  for  the 
purpose  of  inclusion  of  patients  into  immuno- 
therapy clinical  trials  has  resulted  in  complica- 
tions or  changes  in  the  patient's  performance 
status  which  prevents  participation  in  the  trials 
in  20%  of  patients.14  A recent  study  by 
Fleischman  and  Kim15  recommends  using  im- 
munotherapy to  decrease  tumor  burden,  then 
using  surgery  to  obtain  disease-free  survival. 
Which  of  the  approaches  will  eventually  prove 
optimal  remains  the  focus  of  future  studies. 
However,  two  things  are  clear:  First,  radical  ne- 
phrectomy in  the  face  of  known  metastatic  dis- 
ease in  not  indicated  unless  done  as  part  of  a 
clinical  trial  or  to  control  symptoms.  Second, 
even  with  the  best  immunotherapy  available  to 
date,  surgery  is  still  required  at  some  point  to 
secure  a disease-free  state  in  the  vast  majority  of 
patients. 

In  the  face  of  an  isolated  focus  of  recurrent 
or  metastatic  RCC  after  radical  nephrectomy, 
surgery  can  offer  a hope  for  a cure.  Reviewing 
the  literature,  cancer-free  survival  rates  after 
surgical  excision  of  a solitary,  distant  metastasis 


J La  State  Med  Soc  VOL  152  March  2000  121 


have  ranged  from  13%  at  4.5  years  to  53%  at  10 
years.16  These  rates  are  higher,  and  have  been 
proven  to  be  more  durable,  than  those  achieved 
with  any  other  treatment  modality  presently 
available.  With  regard  to  fossa  recurrence,  Esrig 
and  associates17  demonstrated  that  excision  of 
local  recurrences  resulted  in  a 55%  1-year 
survival  rate,  and  a 36%  3-year  disease-free 
survival  rate.  That  can  be  contrasted  to 
deKernion' s finding  of  only  14%  survival  at  1 
year  in  patients  with  local  recurrence  who  did 
not  undergo  resection.3  Granted,  this  extirpative 
surgery  is  technically  difficult  with  high 
morbidity  and  mortality.  Of  the  11  patients  in 
Esrig's  study,  there  were  two  post-operative 
deaths  and  two  significant  complications,  but 
this  only  highlights  the  need  to  aggressively 
resect  all  visible  tumor  at  the  time  of  primary 
surgery,  since  at  present  there  is  not  an  effective 
way  to  "clean-up"  residual  disease  in  the  renal 
fossa.  A study  from  Esho18  demonstrates  this 
point  in  that  aggressive  resection  of  the  tumor 
at  time  of  nephrectomy,  including  resection  of 
the  colon  or  vena  cava  if  necessary,  resulted  in 
66%  survival  at  1 year,  with  44%  disease-free 
survival  rate  at  3 years.  This  study  was 
published  in  1978  and  demonstrates  the 
persistent  superiority  for  surgery  in  the 
treatment  of  RCC. 

CONCLUSION 

Despite  continued  research  and  medical 
advancements,  chemotherapy  and  radiation 
therapy  have  little  to  offer  the  patient  with  RCC, 
whether  it  is  locally  advanced  disease,  isolated 
local  recurrence,  or  widely  metastatic  disease. 
Immunotherapy  has  shown  some  promise  with 
metastatic  disease,  but  not  in  the  face  of  large 
volume  disease  in  the  renal  fossa,  whether 
primary  or  recurrent  disease.  While  surgical 
resection  of  isolated  renal  fossa  recurrence  has 
been  demonstrated  to  produce  durable  cancer- 
free  survival,  the  procedure  is  fraught  with 
difficulties,  and  postoperative  mortality  and 
morbidity  are  significant.  Therefore,  the  best 
hope  for  a durable  cure  for  locally  advanced 


renal  cell  carcinoma  in  the  absence  of  metastatic 
disease  remains  the  aggressive  resection  of  all 
tumor  at  the  time  of  initial  surgery. 

REFERENCES 

1.  Thompson  IM,  Peck  M.  Improvement  in  survival  of 
patients  with  renal  cell  carcinoma:  the  role  of  seren- 
dipitously  detected  tumor.  / Urol  1988;140:487-490. 

2.  Macaluso  JN,  Deutsch  JR,  Voigt  L,  et  al.  Urologic  sound: 
an  evolving  technology.  Southern  Medical  Association 
Annual  Meeting,  New  Orleans,  La,  November  7,  1988. 

3.  Macaluso  JN,  Weichert  R,  Batson  R,  et  al.  Resection  of 
renal  cell  carcinoma  invading  the  right  atrium.  Film, 
52nd  Annual  Meeting  of  Southeastern  Section  of  the 
American  Urologic  Association,  Dorado  Beach,  Puerto 
Rico,  March  1986. 

4.  Skinner  DG,  Pfister  RF,  Colvin  R.  Extension  of  renal 
cell  carcinoma  in  the  vena  cava:  the  rationale  for  aggres- 
sive surgical  management.  J Urol  1972;107:711-  716. 

5.  deKernion  JB,  Ramminy  KP,  Smith  RP.  Natural  history 
of  metastatic  renal  cell  carcinoma:  a computer  analysis. 
J Urol  1978;  20:148-152. 

6.  Montie  JE,  Stewart  BH,  Straffon  RA,  et  al.  The  role  of 
adjunctive  nephrectomy  in  patients  with  metastatic  renal 
cell  carcinoma.  J Urol  1977;117:272-275. 

7.  Hrushesky  WJ,  Murphy  GP.  Current  status  of  the 
therapy  of  advanced  renal  carcinoma.  J Surg  Oncol 
1977;9:277-288. 

8.  Yagoda  A.  Chemotherapy  of  renal  cell  carcinoma:  1983- 
1989.  Semin  Urol  1989;7:199-206. 

9.  Bloom  HJ.  Hormone  induced  and  spontaneous 
regression  of  metastatic  renal  cell  carcinoma.  Cancer 
1973;  32:1066-1071. 

10.  Finney  R.  The  value  of  radiotherapy  in  the  treatment  of 
hypernephroma-a  clinical  trial.  Br  J Urol  1973;45:258- 
269. 

11.  Kao  GD,  Malkowicz  SB,  Whittington  R,  et  al.  Locally 
advanced  renal  cell  carcinoma:  low  complication  rate 
and  efficacy  of  post-nephrectomy  radiation  therapy 
planned  with  CT.  Radiology  1994;193:725-730. 

12.  deKernion  JB,  Belldegrin  A.  Renal  tumors.  In:  Walsh  P, 
Retik  AB,  Stamey  TH,  et  al  (editors).  Campbell's  Urology, 
6th  edition.  Philadelphia:  WB  Saunders;  1992:1053-1093. 

13.  Fisher  RI,  Coltman  CA,  Doroshow  JH,  et  al.  Metastatic 
renal  cancer  treated  with  interleukin-2  and  lymphokine- 
activated  killer  cells:  a phase  II  clinical  trial.  Ann  Int 
Med  1988;108:  518-523. 

14.  Fowler  JE  Jr.  Nephrectomy  in  metastatic  renal  cell 
carcinoma.  Urol  Clin  North  Am  1987;14:749-756. 

15.  Fleischmann  JD,  Kim  B.  Interleukin-2  immunotherapy 
followed  by  resection  of  residual  renal  cell  carcinoma.  / 
Urol  1991;145:938-941. 

16.  Campbell  SC,  Novick  AC.  Management  of  local 
recurrence  following  radical  nephrectomy  or  partial 


122  J La  State  Med  Soc  VOL  152  March  2000 


nephrectomy.  Urol  Clin  North  Am  1994;21:593-599. 

17.  Esrig  D,  Ahlerigy  TE,  Lieskovsky  G,  et  al.  Experience 
with  fossa  recurrence  of  renal  cell  carcinoma.  / Urol 
1992;147:1491-1494. 

18.  Esho  J.  Radical  surgery  for  renal  cell  carcinoma.  Eur 
Urol  1978;4:  338-341. 


Dr  Crotty  is  a urologist  at  the 
Urologic  Institute  of  New  Orleans  and  has  recently 
completed  her  service  in  the  United  States  Air  Force, 
where  she  most  recently  served  as  chief  of  the 
Urology  Section  of  the  Wright-Patterson  AFB 
Medical  Center  in  Louisiana. 

Dr  Macaluso  is  Managing  Director  of 
The  Urologic  Institute  of  New  Orleans,  Louisiana. 


J La  State  Med  Soc  VOL  152  March  2000  123 


Milling 

Benson 

Woodward  l.l.r 


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Diagnosis  and  Management  of 
a Painful  Thyroid  Nodule  in  a Patient 
with  Systemic  Sarcoidosis 

Lester  W.  Johnson,  MD;  James  K.  Sehon,  MD; 
and  John  C.  McDonald,  MD 


Painful  thyroid  nodules  caused  by  sarcoid  are  exceedingly  rare.  Painless  involvement  of 
the  thyroid  by  sarcoid  in  patients  with  systemic  sarcoidosis  is  not.  Several  autoimmune 
thyroid  illnesses  are  closely  linked  to  sarcoid.  These  illnesses  may  form  thyroid  nodules 
which  may  or  may  not  be  painful.  We  present  only  the  second  reported  case  of  a painful 
thyroid  nodule  caused  by  direct  sarcoid  involvement.  Fine  needle  aspiration  may  not 
provide  a definitive  diagnosis  in  patients  whose  appropriate  therapy  would  vary  greatly 
depending  on  this  diagnosis.  When  an  open  surgical  procedure  is  indicated,  total  unilateral 
thyroid  lobectomy  should  be  considered.  Multi-centric  involvement  of  a lobe  with  post- 
operative recurrence  in  remaining  ipsi-lateral  thyroid  tissue  would  be  very  likely  if  the 
entire  lobe  is  not  removed. 


Sarcoidosis  is  a systemic  disease 
characterized  by  the  formation  of  non- 
caseating  granulomas  in  multiple 
tissues.  Pulmonary,  skin,  and  optic  pre- 
sentations predominate.  Thyroid  involvement 
is  not  rare.  Autopsy  examinations  reveal  a 1% 
to  5%  involvement  in  cases  with  systemic 
sarcoidosis.1  Reports  have  also  shown  a group 
of  concomitant  thyroid  diseases  to  be  associated 
with  sarcoidosis.2 

The  case  of  a 40-year-old  woman  with  a 4- 
year  history  of  systemic  sarcoidosis  and  a pain- 
ful thyroid  nodule  is  presented.  Nodules 
caused  by  sarcoid  are  usually  painless.  Nod- 


ules caused  by  some  diseases  associated  with 
sarcoid  may  exhibit  both  pain  and  tenderness. 
This  is  only  the  second  case  which  presented 
with  a painful  thyroid  nodule  due  to  sarcoid.3 
Her  fine  needle  aspirate  was  inconclusive  and 
she  underwent  lobectomy  for  diagnosis  and  cure 
of  this  symptom.  Etiology  and  management  of 
thyroid  nodules  in  sarcoid  patients  is  discussed. 

MATERIALS  AND  SUBJECTS 

The  complete  medical  records  of  a 40-year-old 
woman  with  previously  diagnosed  systemic  sar- 
coidosis were  analyzed  at  Louisiana  State  Uni- 
versity Hospital  in  Monroe,  Louisiana.  All  data 


J La  State  Med  Soc  VOL  152  March  2000  125 


including  history,  physical,  radiology,  and  labo- 
ratory data  were  included.  All  laboratory  stud- 
ies including  tissue  samples,  hematologic  stud- 
ies, thyroid  function,  and  thyroiditis  profiles 
were  performed  by  the  Department  of  Pathol- 
ogy, Louisiana  State  University,  Monroe,  Loui- 
siana. 

CASE  REPORT 

We  present  the  case  of  a 40-year-old  woman  with 
a 4-year  history  of  systemic  sarcoidosis.  Her 
symptoms  were  originally  confined  to  pulmo- 
nary and  joint  involvement.  Diagnosis  of  non- 
caseating  granulomas  had  been  made  by  medi- 
astinal node  biopsy  in  1995.  Prednisone  had  been 
used  intermittently  for  4 years  for  symptomatic 
relief.  Her  base  steroid  level  had  been  main- 
tained at  15-20  mg  of  prednisone  per  day.  Five 
months  prior  to  referral  to  the  surgery  service 
she  had  developed  a painful  nodule  in  the  left 
lobe  of  her  thyroid.  She  denied  any  history  of 
other  thyroid  symptoms  and  had  no  family  his- 
tory of  thyroid  diseases.  Her  thyroid  function 
studies  and  thyroiditis  profile  were  normal.  All 
other  laboratory  studies  were  within  normal  lim- 
its including  a normal  ANA.  Abnormality  of  her 
physical  examination  was  confined  to  a tender 
1 cm  hard  nodule  in  the  left  lobe  of  her  thyroid. 
A few  small  cervical  lymph  nodes  were  palpable 
bilaterally.  1123  scan  revealed  a 1 cm  hypoechoic 
nodule  in  the  left  mid-lobe.  She  was  placed  on 
thyroid  suppression  with  Synthroid  0.125  mg 
and  continued  on  prednisone  20  mg  per  day.  Her 
TSH  level  decreased  to  0.08  mlU/mL  after  sup- 
pression with  Synthroid.  Fine  needle  aspiration 
was  performed.  It  was  inconclusive  for  diagnos- 
tic purposes  on  two  occasions.  No  decrease  in 
size  or  tenderness  of  the  nodule  was  noted  after 
4 months  of  suppressive  therapy.  After  thorough 
discussion  with  the  patient  she  was  taken  to  sur- 
gery where  a left  lobectomy  was  performed.  Fro- 
zen section  and  permanent  sections  of  the  nod- 
ule revealed  multiple,  scattered,  non-caseating 
epithelioid  granulomas  consistent  with  sarcoi- 
dosis. Special  stains  and  cultures  for  fungi  and 
acid  fast  bacilli  were  negative.  The  patient  had 


an  uneventful  recovery  from  her  thyroid  surgery. 
She  is  maintained  on  prednisone  10-15  mg  per 
day  for  systemic  symptoms  of  sarcoid  at  this 
time. 

DISCUSSION 

Sarcoidosis  involving  the  thyroid  gland  is  usu- 
ally confirmed  by  the  finding  of  non-caseating 
granulomas  in  the  thyroid  gland  in  a patient  with 
known  systemic  findings  of  the  disease.  Isolated 
involvement  of  the  thyroid  is  rare  although  it 
has  been  reported.4  A positive  Kveim  test  or  posi- 
tive biopsy  of  nodal  or  other  tissues  usually  ac- 
company the  histologic  thyroid  examination. 
Sarcoid  involvement  of  the  thyroid  is  usually 
painless.  In  known  sarcoid  patients,  thyroid 
function  tests,  thyroiditis  profiles,  and  thyroid 
scans  have  been  used  extensively  to  determine 
its  synchronous  occurrence  with  Graves  disease, 
De  Quervain  or  Hashimoto  thyroiditis,  systemic 
lupus  erythematosis,  and  various  other  autoim- 
mune disorders.  These  disorders  are  known  to 
affect  the  thyroid  in  inordinately  large  numbers 
of  sarcoid  patients.  Numerous  reports  in  the  lit- 
erature have  indicated  that  coexistence  of  these 
diseases  with  sarcoid  is  far  more  than  coinciden- 
tal.25 A possible  common  etiology  is  not  appar- 
ent at  this  time.  Pain  and  tenderness  may  often 
be  present  in  nodules  caused  by  these  illnesses 
during  periods  of  acute  inflammation  whereas 
it  is  extremely  rare  in  direct  thyroid  involvement 
by  sarcoid. 

The  great  majority  of  thyroid  nodules  and 
thyroid  conditions  associated  with  sarcoid  are 
benign.  Papillary  carcinoma,  lymphoma,  and 
Hurthle  cell  hyperplasia  have  also  been  reported 
with  sarcoid.67  Fine  needle  aspiration  may  not 
always  differentiate  benign  from  malignant 
changes. 

Sarcoidosis  must  also  be  differentiated  from 
infectious  causes  of  granulomatous  thyroiditis. 
Tuberculous  and  fungal  thyroiditis  must  be  con- 
sidered in  any  case  where  granulomas  are 
present.  In  these  infections,  caseation  may  not 
be  present  and  necrosis  may  not  always  occur. 
Fine  needle  aspiration  may  once  again  be  un- 


126  J La  State  Med  Soc  VOL  152  March  2000 


REFERENCES 


able  to  fully  differentiate  between  these  ill- 
nesses. The  treatments  for  these  conditions  vary 
greatly.  Immuno-suppression  may  be  useful  in 
sarcoidosis  but  contraindicated  for  acute  fun- 
gal or  mycobacterial  infection. 

Foreign  body  reaction,  DeQuervain  thy- 
roiditis, palpation  thyroiditis,  Hashimoto  thy- 
roiditis, and  silent  thyroiditis  may  show  granu- 
lomatous reaction.8  Hashimoto  and  DeQuer- 
vain exhibit  a definite  increased  incidence  in 
sarcoid  patients. 

Fine  needle  aspiration  is  the  first  examina- 
tion indicated  in  the  evaluation  of  thyroid  nod- 
ules. It  is  often  able  to  identify  their  etiology 
with  great  accuracy  and  sensitivity.  Inconclu- 
sive fine  needle  aspirations  may  also  occur  in 
these  settings.  The  multiplicity  of  known  con- 
comitant illnesses,  some  of  which  are  often 
granulomatous,  and  the  possibility  of  malig- 
nancy makes  open  surgical  procedures  often 
necessary  for  diagnostic  or  curative  purposes. 

When  an  open  procedure  is  undertaken, 
total  lobectomy  should  be  considered  due  to 
the  possibility  of  multi-centric  disease  in  a lobe 
and  the  probability  of  recurrence  in  remaining 
ipsi-lateral  tissue.  Completion  thyroidectomy 
is  indicated  in  the  cases  of  malignancy,  mass 
formation  in  the  opposite  lobe,  or  in  patients 
who  have  received  previous  radiation  to  their 
head  and  neck. 

CONCLUSION 

Patients  with  sarcoidosis  may  rarely  have  pain- 
ful nodules  develop  in  their  thyroid.  Nodules 
may  develop  from  direct  involvement  by  sar- 
coid or  as  a symptom  of  other  thyroid  diseases 
associated  with  sarcoidosis.  Fine  needle  aspi- 
ration may  fail  to  define  a diagnosis  in  some 
patients.  When  an  open  procedure  is  under- 
taken thyroid  lobectomy  should  be  considered. 


1.  Vailati  A,  Marena  C,  Aristia  L,  et  al.  Sarcoidosis  of  the 
thyroid:  report  of  a case  and  a review  of  the  literature. 
Sarcoidosis  1993;10:66-68. 

2.  Warshawsky  ME,  Shanies  HM,  Rozo  A.  Sarcoidosis 
involving  the  thyroid  and  pleura.  Sarcoidosis  Vasculitis 
and  Diffuse  Lung  Diseases  1997;14:165-168. 

3.  Cilley  RE,  Thompson  NE,  Lloyd  RV,  et  al.  Sarcoidosis 
of  the  thyroid  presenting  as  a painful  nodule. 
Thyroidology  1988;1:61-62. 

4.  Mizukami  Y,  Nonomura  A,  Michigishi  T,  et  al. 
Sarcoidosis  of  the  thyroid  gland  manifested  initially 
as  thyroid  tumor.  Path  Res  Pract  1994;190:1201-1205. 

5.  Papadopoulos  KI,  Homblad  Y,  Liljebladh  H,  et  al.  High 
frequency  of  endocrine  autoimmunity  in  patients  with 
sarcoidosis.  Eur  Endocrinol  1996;134:331-336. 

6.  Middleton  WG,  deSouza  FM,  Gardiner  GW.  Papillary 
carcinoma  of  the  thyroid  associated  with  sarcoidosis. 
Otolaryngology  1985;14:4. 

7.  Bacci  V,  Giammarco  V,  Germani  G,  et  al.  Hurthle  cell 
hyperplasia  and  sarcoidosis  of  the  thyroid.  Arch  Pathol 
Lab  Med  1991;115:1044-1046. 

8.  Harach  HR,  Williams  ED.  The  pathology  of 
granulomatous  diseases  of  the  thyroid  gland. 
Sarcoidosis  1990;7:19-27. 


Dr  Johnson  is  an  associate  professor  of  Surgery  at 
Louisiana  State  Uuniversity  Medical  Center- 
Shreveport  and  the  Director  of  Surgery  at 
Louisiana  State  University  Medical  Center-Monroe. 

Dr  Sehon  is  an  associate  professor  of  Surgery  at 
Louisiana  State  University  Medical  Center-Monroe. 

Dr  McDonald  is  a professor  of  Surgery  at 
Louisiana  State  University  Medical  Center-Shreveport. 


J La  State  Med  Soc  VOL  152  March  2000  127 


Ca' 


April  2000 


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128  J La  State  Med  Soc  VOL  152  March  2000 


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ESTABLISHED  1844 


Of  the  Louisiana  State  Medical  Society 


Special  Issue:  Cancer  in  Louisiana 


The  Louisiana  Cancer  and  Lung  Trust  Fund  Board 
A Guide  to  Act  199:  The  Treatment  of  Breast  Cancer 
Stage  of  Disease  at  Diagnosis  and  Survival  Estimates  for  Cancers  of  the  Colon  and  Rectum 
Long  Term  Survival  of  Mice  that  Express  Dominant  Negative  p53  in  the  Lung 
Selenium:  Increasing  Evidence  of  Effective  Cancer  Chemoprevention 
Incidence,  Trends,  and  Mortality  Rate  of  Prostate  Cancer  in  Louisiana 


/ Breast 

Cancer 


Utilizing  our  new  Vista  rolaris  MKI  with 
27  mT  PowerDrive  gradients,  some  of  the  most 
powerful  gradients  currently  approved  by  the 
FDA,  peripheral  MR  Angiography  studies  of  the 
lower  extremities  are  greatly  improved  and  can 
serve  as  an  alternative  to  invasive  conventional 
angiography.  Medicare  now  provides 
coverage  and  has  approved  MRA 
as  an  appropriate  test  in  determining 
the  extent  of  peripheral  vascular 
disease  in  the  lower  extremities. 
Additionally,  MRA  has  been  shown  to  find 
occult  flow  in  blood  vessels  where  it  was  not 
apparent  on  conventional  angiography. 

MRA  is  a non-invasive  test  and  requires 
no  iodinated  contrast,  which  reduces  the  risk 
of  complications  and  allergic  reactions.  So,  if 
you  have  a patient  who  would  benefit  from  an 
MRA  study  of  the  lower  extremities,  call  DIS  at 


■ Diagnostic 
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Editor 

CONWAY  S.  MAGEE,  MD 

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DAVE  TARVER 

General  Manager 

CATHY  LEWIS 


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ANNE  SHIRLEY 

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ANNE  GOOCH 

BOARD  OF  TRUSTEES 
Chairman,  CONWAY  S.  MAGEE,  MD 
K.  BARTON  FARRIS,  MD 
Ex  officio,  C.  Clinton  Lewis,  MD 

EDITORIAL  BOARD 
A.  JOANNE  GATES,  MD 
RODNEY  C.  JUNG,  MD 
PATRICK  W.  PEAVY,  MD 
TRENTON  L.  JAMES  II,  MD 
JACK  P.  STRONG,  MD 
CLAY  A.  WAGGENSPACK  JR,  MD 
WINSTON  H.  WEESE,  MD 

LSMS  BOARD  OF  GOVERNORS 
C.  CLINTON  LEWIS,  MD 
DUDLEY  M.  STEWART,  MD 
KEITH  DESONIER,  MD 
LEO  L.  LOWENTRITT  JR,  MD 
K.  BARTON  FARRIS,  MD 
RUSSELL  C.  KLEIN,  MD 
WALLACE  H.  DUNLAP,  MD 
VINCENT  A.  CULOTTA  JR,  MD 
RICHARD  J.  PADDOCK,  MD 
BARRY  G.  LANDRY,  MD 
WILLIAM  T.  HALL,  MD 
JOSEPH  BUSBY  JR,  MD 
LYNN  Z.  TUCKER,  MD 
R.  MARK  WILLIAMS,  MD 
MARTIN  B.  TANNER,  MD 
MARTIN  J.  DUCOTE  JR,  MD 
MARCUS  L.  PITTMAN  III,  MD 
CHARLES  D.  BELLEAU,  MD 
JOSHUA  LOWENTRITT,  MD 
LAURA  BRESNAHAN 

ESTABLISHED  1844.  Owned  and  edited  by  the 
Journal  of  the 
Louisiana  State  Medical  Society , Inc., 
6767  Perkins  Road.  Baton  Rouge.  LA  70808; 
phone:  (225)  763-2310;  fax  (225)  763-2332. 

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Internet  www.lsms.org 

Copyright  2000  by  the  Journal  of  the 
Louisiana  State  Medical  Society,  Inc. 

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The  Journal  of  the  Louisiana  State  Medical  Society 

(ISSN  0024-6921)  is  published  monthly 
at  6767  Perkins  Road,  Louisiana  State  Medical  Society, 
Baton  Rouge,  LA  70808. 
Periodical  postage  paid  at  Baton  Rouge,  LA 
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Articles  and  Advertisements  published  in  the  Journal 
are  for  the  interests  of  its  readers  and  do  not 
necessarily  represent  the  official  position  or 
endorsement  of  the  Journal  of  the  Louisiana 
State  Medical  Society,  Inc.  or  the 
Louisiana  State  Medical  Society. 

The  Journal  reserves  the  right  to  make  the  final 
decision  on  all  contents  and  advertisements. 


Of  the  Louisiana  State  Medical  Society 


Articles 


Ray  S.  Whiting 
Donna  Williams,  MS,  MPH 

161 

The  Louisiana  Cancer  and  Lung 
Trust  Fund  Board 

Donna  L.  Williams,  MS,  MPH 
Charles  L.  Brown,  Jr,  MD 

165 

A Guide  to  Act  199:  The  Treatment 
of  Breast  Caner 

Xiao  Cheng  Wu,  MD,  MPH,  CTR 
Catherine  N.  Correa,  MPH,  PhD 
Patricia  A.  Andrews,  MPH,  CTR 
Beth  A.  Schmidt,  MSPH 
Mohammed  N.  Ahmed,  MD,  MPH 
Vivien  W.  Chen,  PhD 
Elizabeth  T.H.  Fontham,  DrPH 

171 

Stage  of  Disease  at  Diagnosis  and 
Survival  Estimates  for  Cancers  of  the  Colon 
and  Rectum  in  Louisiana 

Tamra  Mendoza,  BS 
Anne  B.  Nelson,  PhD 
Sushmita  Ghosh,  PhD 
Cindy  B.  Morris,  PhD 
Gary  WL.  Hoyle,  PhD 
Arnold  R.  Brody,  PhD 
Mitchell  Friedman,  MD 
Gilbert  F.  Morris,  PhD 

181 

Long  Term  Survival  of  Mice  that  Express 
Dominant  Negative  p53  in  the  Lung 

Oliver  Sartor,  MD 

190 

Selenium:  Increasing  Evidence  of  Effective 
Cancer  Chemoprevention 

Mohammed  N.  Ahmed,  MD,  MPH 
Patricia  A.  Andrews,  MPH,  CTR 
Vivien  W.  Chen,  PhD 
Xiao  Cheng  Wu,  MD,  MPH,  CTR 
Catherine  N.  Correa,  MPH,  PhD 
Beth  A.  Schmidt,  MSPH 
Elizabeth  T.H.  Fontham,  DrPH 

195 

Incidence,  Trends,  and  Mortality  Rate  of 
Prostate  Cancer  in  Louisiana 

Departments 


C.  Clinton  Lewis,  MD 


Jorge  I.  Martinez-Lopez,  MD 


Stephen  B.  Schaffer,  MD 
Ronald  G.  Amedee,  MD,  MPH 


136  INFORMATION  FOR  AUTHORS 

137  PRESIDENTS  MESSAGE 
Physician  Involvement  Leads  to 
Good  Medicine 

139  ECG  OF  THE  MONTH 
Disturbing  Findings 

142  OTOLARYNGOLOGY/HEAD  & NECK 
SURGERY  REPORT 
Superior  Laryngeal  Nerve  Injury  After 
Thyroid  Surgery 


Sanjay  M.  Patel,  MD 
Harold  Neitzschman,  MD 
Joseph  Higgins  Jr,  MD,  PhD 

James  F.  Martin,  BS 
Hector  O.  Ventura,  MD 


Eugene  New 
New  Orleans 


148  RADIOLOGY  CASE  OF  THE  MONTH 
Lower  Extremity  Bruit 


151  HISTORY  OF  MEDICINE 

Frontal  Lobe  Damage  and  the  Case  of 
Phineas  Gage 

156  LSMS  RESIDENT  SECTION 

Residency  Programs  Cited  for  Noncompliance 


159  LOUISIANA  HEALTH  CARE  REVIEW 
Planning  for  Influenza  Season  2000 


204  CALENDAR 


208  CLASSIFIED  ADVERTISING 

J La  State  Med  Soc  VOL  152  April  2000  135 


Information  for  Authors 


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1.  Brush  JE  Jr,  Cannon  RO  III,  Schenke  WH,  et  al.  Angina  due  to  coro- 
nary microvascular  disease  in  hypertensive  patients  without  left  ven- 
tricular hypertrophy.  N Engl  J Med  1988;319:1302-1307. 

2.  Hajdu  SI.  Pathology  of  Soft  Tissue  Tumors.  Philadelphia,  Pa:  Lea  & 
Febiger;  1979:60-83. 

3.  Robinson  BH.  Lactic  acidemia.  In:  Scriver  CR,  Beaudet  AL,  Sly  WS, 
et  al  (editors).  The  Metabolic  Basis  of  Inherited  Disease , 6th  edition. 
New  York:  McGraw-Hill;  1989:869-888. 

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Editor,  Journal  of  the  Louisiana  State  Medical  Society 
6767  Perkins  Rd. 

Baton  Rouge,  LA  70808 


136  J La  State  Med  Soc  VOL  152  April  2000 


President’s  Messaae 


Physician  Involvement 
Leads  to  Good  Medicine 

C.  Clinton  Lewis,  MD 


On  March  27, 2000,  Executive  Vice  President 
of  the  American  Medical  Association 
(AMA)  E.  Ratchliffe  Anderson  Jr,  MD 
addressed  the  AMA  National  Leadership 
Development  Conference.  In  his  remarks,  Dr 
Anderson  addressed  an  increasing  need  for  and  trend 
in  favor  of  physician  involvement  in  organized 
medicine.  I would  like  to  share  some  of  my  own 
thoughts  on  this  subject. 

All  of  us  in  organized  medicine  are  doing  what 
we  are  doing  - not  for  politics,  not  for  headlines,  or 
for  the  greater  glory  of  ourselves  and  our  practices. 
No,  we  are  striving  to  preserve  the  core  values  of 
high  quality  care  and  the  role  of  physicians  as  strong 
and  effective  advocates  for  the  needs  of  their  patients. 
That’s  the  solid  foundation  that  supports  our 
involvement  in  organized  medicine.  All  that  we 
achieve  helps  every  physician  whether  they  pay  their 
dues  or  show  up  at  meetings.  The  leadership  at  all 
levels  has  not  done  enough  to  convey  the  relevance 
of  organized  medicine  to  the  medical  community. 

We  say  get  on  board.  Pull  your  weight.  We  need 
everyone,  their  resources,  and  even  more  important, 
their  representative  voices.  With  that,  our  power 
grows  exponentially. 


If  we  could  take  on  the  insurance  company 
bureaucrats  and  our  state  and  federal  legislators  and 
regulations  with  all  of  the  physicians  of  America 
together  and  show  them  we  are  really  united  and 
representing  our  patient,  we  would  be  invincible.  We 
have  enormous  potential  clout.  We  need  to  make  every 
physician  aware  of  what  we  have  achieved  together. 

An  increase  in  Medicare  physician  payments  of 
5.4%  went  into  effect  January  1,  2000,  the  improved 
Medicare  Sustainable  Growth  Rate,  the  largest 
Medicare  payment  rate  increase  since  the  first  RBRVS 
nearly  8 years  ago. 

Support  for  the  Campbell  Bill  to  provide  antitrust 
relief  to  make  it  legal  for  self-employed  physicians  to 
negotiate  collectively  with  health  plans,  comes  from 
organized  medicine. 

Patients’  Bill  of  Rights  comes  from  the  efforts  of 
organized  medicine. 

All  of  these  involve  a lot  of  energy,  knocking  on 
doors  in  Washington  and  at  home.  We  are  using  our 
collective  influence  to  make  a real,  positive  difference 
for  patients  and  the  profession. 

The  constant  pressure  of  organized  medicine  has 
health  plans  and  insurers  on  the  run.  Organized 
medicine  has  become  the  standard  bearer  awakening 


J La  State  Med  Soc  VOL  152  April  2000  137 


the  American  public  to  the  mischief  of  health  plans. 
The  health  plans  and  insurers  are  becoming  aware 
that  the  common  unified  voice  of  organized  medicine 
is  a force  to  be  reckoned  with.  Patients  want  to  listen 
to  their  physicians,  not  their  health  plans. 

The  patient  and  providers  should  be  reimbursed 
for  that  which  was  contracted  for,  not  what  the 
insurance  carrier  decided  to  pay.  A class  action 
lawsuit  with  the  AMA  and  the  Medical  Society  of 
the  State  of  New  York  is  attempting  to  remedy 
systemized  underpayment  of  physicians  and  leaving 
their  patients  paying  much  more  than  provided  for 
by  the  terms  of  their  contracts. 

In  Georgia,  a joint  suit  claims  Aetna  is  not 
satisfying  the  Georgia  law  for  prompt  payment. 

The  Pennsylvania  Medical  Society  and  the  AMA 
have  asked  the  US  Department  of  Justice  Antitrust 
Division  to  investigate  two  health  plans  for 
agreement  not  to  compete  to  help  maintain  market 
dominance. 

Such  market  dominance  restricts  patient  choice 
and  allows  health  plans  to  unilaterally  dictate 
contract  provisions.  This  allows  plans  to  reap 
substantial  profits  by  raising  premiums  for  patients 
and  employers  and  lowering  payments  to  those 
providing  patient  care. 

When  a health  plan  controls  more  than  50%  of 
the  market,  physicians  cannot  simply  drop  out  of  a 
network  to  redress  the  plan’s  antipatient  care 
policies.  Without  sufficient  competition  patients  are 
forced  to  receive  their  health  care  from  a controlling 
insurer  leaving  little  or  no  choices. 

We  are  working  to  rebalance  the  health  care 
equation  to  put  physicians  and  patients  at  the  center, 
not  the  insurers  and  health  plans.  The  real  value  is 
created  between  the  patient  and  the  physician.  All 
the  insurance  plans  and  health  plans  are  simply 
supporters.  Because  physicians  are  truly  those  who 
create  the  value  in  the  health  care  equation,  they  need 
to  be  treated  in  a way  that  makes  them  feel  valued. 


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issues,  medical  malpractice  defense  and  risk 
management. 

Nicholas  Gachassin,  Jr.  Nicholas  Gachassin,  III 

Susan  Severance  Richard  MacMillan 

T.  Rose  Young  Thomas  H.  Morrow 

Julie  Hoffpauir 

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Telephone:  (337)  235-4576  Fax:  (337)  235-5003 
E-Mail:  gh@gachassin.com 
www.gachassin.com 


to# 


138  J La  State  Med  Soc  VOL  152  April  2000 


ECG  of  the  Month 


Disturbing  Findings 

Jorge  I.  Martinez-Lopez,  MD 


The  continuous  rhythm  strip  shown  below,  precordial  lead  V6,  belongs  to  a 67-year-old  woman. 
It  was  recorded  after  her  admission  to  the  hospital  with  a diagnosis  of  acute  myocardial 
infarction".  No  other  information  was  attached  to  the  tracing. 


What  is  your  diagnosis? 
Elucidation  begins  on  page  140. 


J La  State  Med  Soc  VOL  152  April  2000  139 


ECG  of  the  Month 
Presentation  is  on  page  139. 

DIAGNOSIS  - See  below. 

This  single  lead  was  all  that  was  found  on  this 
unidentified  woman,  and  it  shows  disturbing 
findings.  The  paucity  of  data  and  the  abnormal 
findings  make  the  interpretation  of  the  tracing  a 
challenge  because  it  raises  more  questions  than 
it  answers. 

To  begin  with,  a careful  search  for  atrial  elec- 
trical activity  reveals  none:  there  are  no  P waves, 
no  atrial  flutter  waves,  and  no  atrial  fibrillatory 
waves.  Such  absence  of  atrial  electrical  activity 
favors  a diagnosis  of  atrial  standstill. 

In  the  absence  of  atrial  electrical  activity,  sub- 
sidiary cardiac  pacemakers,  either  in  the  AV 
junctional  tissues  or  in  the  ventricular  myocar- 
dium, may  be  recruited  to  drive  the  ventricles. 
The  tracing  shows  wide  QRS  complexes  (0.14 
sec)  recurring  at  regular,  constant  intervals,  but 
at  a very  slow  rate  (about  20  times  a minute). 
These  findings  suggest  that  an  idioventricular 
escape  rhythm  drives  the  ventricles.  The  very 
slow  rate  of  firing  is  of  concern  because  it  sug- 
gests that  the  intrinsic  automaticity  of  the  escape 
focus  is  abnormally  depressed. 

At  the  very  beginning  of  the  top  panel,  a third 
abnormality  is  found:  a sharp,  negative  deflec- 
tion with  an  amplitude  of  12  mm  in  depth.  Iden- 
tical deflections  (spikes)  are  found  in  all  3 pan- 
els; they  also  recur  regularly,  with  constant  spike- 
to-spike  intervals,  at  about  30  times  a minute. 
These  spikes  are  caused  by  electrical  discharges 
from  an  artificial  cardiac  pacemaker  generator. 

Other  conclusions,  relative  to  the  artificial 
cardiac  pacemaker,  can  be  deduced  by  further 
examination  of  the  tracing.  First , the  large  am- 
plitude of  the  spikes  suggests  that  a unipolar 
lead  electrode  is  in  use;  spikes  caused  by  bipo- 
lar units  are  smaller  because  the  dipole  is  inside 
the  heart.  Second,  because  none  of  the  spikes 
is  followed  by  temporally-related  atrial  or 
ventricular  responses,  the  location  of  the  elec- 
trode catheter  cannot  be  established.  Third,  im- 
planted pacemakers  are  designed  to  sense  the 


patient's  intrinsic  cardiac  electrical  activity  (the 
P wave,  the  QRS,  or  both),  and  to  respond  ap- 
propriately (to  pace  or  not  to  pace)  in  the  right 
atrium,  right  ventricle,  or  both,  according  to  their 
mode  of  pacing  and  programmability.  The  trac- 
ing shows  complete  dissociation  between  the 
spikes  and  the  QRS  complexes.  In  other  words, 
although  the  pacemaker  is  firing,  it  is  firing  con- 
stantly and  is  neither  sensing  nor  pacing.  Fourth, 
the  very  slow  rate  of  firing  of  the  pacemaker  is 
also  troublesome,  as  it  would  imply  malfunction 
of  the  pacemaker  impulse  generator. 

And  there  is  more!  Note  that  the  QT  interval 
is  also  very  long,  measuring  about  1.12  sec.The 
QT  interval,  measured  from  the  beginning  of  the 
QRS  to  the  end  of  the  T wave,  is  the  sum  total  of 
ventricular  depolarization  and  ventricular  repo- 
larization. For  this  reason,  the  QT  interval  may 
become  prolonged  when  one  or  more  of  its  3 
components  (the  QRS,  the  ST  segment,  the  T 
wave)  is  lengthened.  Different  clinical  conditions 
may  cause  prolongation  of  the  QT  interval.  More 
commonly,  the  long  QT  interval  results  from 
lengthening  of  the  ST  segment  or  broadening  of 
the  T waves.  On  this  tracing,  the  lengthening  of 
the  QT  interval  appears  to  be  due  to  prolonga- 
tion of  all  3 components. 

In  addition  to  the  abnormal  QT  interval,  the 
T wave  is  inverted  in  We,  a lead  in  which  upright 
T waves  are  the  rule.  Its  inversion  here  may  be 
secondary  to  the  recent  infarction  or  to  the  wide 
QRS  that  precedes  it. 

This  tracing  illustrates  the  frustration  that 
may  occur  when  one  attempts  to  interpret  in- 
complete tracings  in  isolation,  without  ad- 
equate data,  and  no  way  to  get  a follow-up. 
Nevertheless,  we  have  gone  this  far  in  the  inter- 
pretation; it  is  now  appropriate  to  separate  what 
appears  to  be  certain  from  that  which  is  not  so 
certain.  It  is  reasonable  to  conclude  that  (a)  there 
is  an  artificial  cardiac  pacemaker  and  that  it  is 
not  functioning  properly  and  (b)  atrial  standstill 
may  be  present.  The  possibility  of  fine  atrial  fi- 
brillation is  another  consideration.  But  if  it  were 
present,  the  regularly  recurring  ventricular  com- 
plexes would  indicate  that  atrial  fibrillation  is 
complicated  by  complete  AV  block;  irregular  ir- 


140  J La  State  Med  Soc  VOL  152  April  2000 


regularity  of  ventricular  rate  and  rhythm  are 
characteristic  findings  in  atrial  fibrillation. 

About  what  is  there  uncertainty?  The 
main  concern  in  the  interpretation  of  the  tracing 
revolves  around  the  word  "intervals".  Why  are 
the  pacemaker  spikes  so  far  apart?  Why  is  the 
so-called  idioventricular  escape  rhythm  so  slow? 
Why  is  the  QT  interval  so  long?  In  fact,  every- 
thing, except  for  the  pacemaker  spikes  them- 
selves, seems  to  be  "stretched  out".  My  suspi- 
cion is  that  the  tracing  was  inadvertently  re- 
corded at  50  mm/ sec,  at  twice  the  speed  of  the 
conventional  25  mm/ sec.  We'll  never  know  for 
sure! 


Dr  Martinez-Lopez  is  a specialist  in  cardiovascular 
diseases  affiliated  vith  the  Cardiology  Service . Depart- 
ment of  Medicine,  Texas  Tech  University  Health  Sciences 
Center  and  Thomason  General  Hospital  in  El  Paso.  Texas. 


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the  Beat 


and  a lot  more  about  the  business  of  health  care. 


At  McGlinchey  Stafford,  we  know  that  if  you're  in  the  business  of 
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J La  State  Med  Soc  VOL  152  Apn  2000  141 


Otolaryngology/ 

urgerv 


Superior  Laryngeal  Nerve  Injury 
After  Thyroid  Surgery 

Stephen  B.  Schaffer,  MD  and  Ronald  G.  Amedee,  MD,  MPH 


Injury  to  the  superior  laryngeal  nerve  is  a recognized  complication  of  thyroid  surgery, 
which  can  lead  to  anesthesia  of  the  supraglottic  larynx  and  paralysis  of  the  cricothyroid 
muscle.  Long-term  vocal  deficits  are  the  most  persistent  complaint  of  patients  and  can  be 
especially  debilitating  for  singers,  actors,  or  patients  with  careers  requiring  a great  amount 
of  speaking.  The  prevention,  recognition,  and  treatment  options  for  this  injury  are  discussed. 

understanding  of  the  presentation,  prevention, 
and  treatment  options  of  superior  laryngeal 
nerve  injury  is  an  important  consideration  in 
patients  with  chronic  voice  dysfunction. 

ETIOLOGY 

The  etiology  of  isolated  superior  laryngeal  nerve 
injury  is  not  well  characterized.  Subtle  clinical 
findings  and  elusive  findings  by  laryngoscopy 
have  likely  led  to  under-reporting  or 
misdiagnosis.  It  is  thought  that  injury  to  the 
nerve  has  the  same  causes  as  recurrent  nerve 
paralysis,  including  viral  neuropathy,  neck 
cancers,  and  idiopathic  injury.2  Injury  has  been 
reported  at  varying  levels  including  the 
brainstem.3 

Surgical  trauma  is  considered  to  be  the  most 

142  J La  State  Med  Soc  VOL  152  April  2000 


Injury  to  the  voice  after  thyroid  surgery  due 
to  nerve  injury  is  a well-recognized 
complication.  Patients  with  a recurrent 
laryngeal  nerve  injury  often  present  with 
symptoms  of  vocal  disturbance,  breathing 
compromise,  and  vocal  cord  mobility 
dysfunction  that  is  readily  detected  by  indirect 
laryngoscopy.  As  a result,  the  incidence  is  well 
documented,  ranging  from  0.3%  to  13%  in  most 
series.1  Injury  to  the  superior  laryngeal  nerve, 
however,  is  another  potential  complication  of 
thyroid  surgery  that  is  frequently  overlooked. 
Detection  of  this  injury  is  difficult  by 
laryngoscopy  and  long-term  vocal  deficits  are 
often  relatively  subtle,  except  in  patients  such 
as  singers,  actors,  and  orators  whose  career 
demands  a fully  functioning  larynx.  An 


common  cause  of  nerve  injur}7  below  the  nodose 
ganglion,  estimated  to  be  between  20%  and  30% 
of  total  injur}7  causes.4  The  most  frequent  injur}7 
is  damage  to  the  motor  branch  during  thyroidec- 
tomy. Bilateral  paralysis  of  the  superior  laryn- 
geal nerves  is  also  most  frequently  secondary  to 
surgical  procedures,  such  as  supraglottic  laryn- 
gectomy. Reports  of  superior  laryngeal  nerve 
injur}7  have  also  been  reported  for  endarterec- 
tomy, parathyroid  surgery,  neck  dissection,  and 
laminectomy  from  an  anterior  approach.5 

INCIDENCE  OF  INJURY 

The  incidence  of  superior  laryngeal  nerve  injurv 
(external  branch)  has  been  investigated  by  nu- 
merous authors  with  varying  results  (Table).4 
Traditionally,  incidence  secondary  to  thyroid 
surgery  has  been  described  as  about  the  same 
as  recurrent  nerve  damage,  around  5%  (Table). 

The  addition  of  electromyography  (EMG), 
which  yields  the  most  objective  criteria  for  evalu- 
ation of  cricothyroid  dysfunction,  has  led  to  a 
relative  increase  in  reported  injur}7.  Jansson  et 
al4  reported  signs  of  superior  laryngeal  nerve 
dysfunction  in  greater  than  one  half  of  all  pa- 
tients undergoing  thyroidectomy.  No  effort  was 
made  in  this  series  to  locate  the  external  branch, 
and  the  high  incidence  can  likely  be  attributed 
to  poor  dissection  technique. Teitelbaum  et  al4 
reported  careful  dissection  of  both  the  internal 
and  external  divisions  of  the  superior  nerve  in 
their  series  and  found  an  injur}7  incidence  simi- 
lar to  that  of  recurrent  laryngeal  nerve  injurv 
after  thyroidectomy,  approximately  5%. 

The  largest  study  to  date  investigating  the 
incidence  of  superior  laryngeal  nerve  injur}7  was 
undertaken  by  Kark  in  1984.6  The  control  arm 
of  the  study  included  a retrospective  review  of 
325  patients  who  complained  of  persistent  voice 
problems  (longer  than  1 year)  after  thyroidec- 
tomy. Criteria  included  changes  of  voice  pitch, 
range,  intensity,  manageability  and  quality  of  the 
singing  voice,  and  documentation  in  all  charts 
that  the  recurrent  nerve  had  been  located  and 
carefully  dissected.  Permanent  subjective  voice 
changes  occurred  in  25%  of  patients  after  subto- 


tal thyroidectomy  and  11%  after  lobectomy.  In 
the  prospective  arm  of  this  experiment,  38  pa- 
tients were  evaluated  postoperatively  after  sub- 
total thyroidectomy  or  lobectomy  in  which  care- 
ful identification  of  both  the  recurrent  and  ex- 
ternal laryngeal  nerves  was  undertaken.  In  this 
series  only  5%  of  patients  complained  of  perma- 
nent vocal  change  after  1 year.  The  conclusion 
of  this  study  was  that  careful  identification  of 
the  external  branch  of  the  superior  laryngeal 
nerve  was  likely  responsible  for  the  decrease  in 
post-surgical  voice  complications. 

ANATOMY 

The  superior  laryngeal  nerve  carries  a number 
of  nerve  fiber  types,  including  the  major  por- 
tion of  the  sensor}7  axons  originating  in  the  lar- 
ynx, motor  fibers  innervating  the  cricothyroid 
muscle,  and  autonomic  fibers.  It  arises  from  the 
vagus  nerve  at  the  nodose  ganglion  in  the 
parapharyngeal  space  and  descends  laterally 
along  the  inferior  constrictor.  There  is  an  inti- 
mate anatomic  relationship  with  the  superior 
laryngeal  artery  and  the  superior  thyroid 
pedicle.  The  nerve  divides  lateral  to  the  hyoid 
bone  into  an  internal  and  external  branch  (Fig- 
ure 1). 

Superior 
laryngeal  nerve 


/ 


Superior  thyroid 
artery 


Figure  1 . Anatomy  of  the  superior  laryngeal  nerve  illus- 
trating the  intimate  relationship  between  the  SLN  and 
the  superior  thyroid  artery. 


J La  State  Med  Soc  VOL  152  April  2000  143 


The  internal  branch  penetrates  the  thyrohy- 
oid ligament  to  innervate  the  interior  surface  of 
the  larynx  and  is  responsible  for  the  sensory  per- 
ception of  the  supraglottic  larynx,  which  in- 
cludes the  epiglottis,  aryepiglottic  folds,  false 
cords,  and  superior  surface  of  the  laryngeal  ven- 
tricle. There  are  several  times  more  sensory  fi- 
bers arising  from  the  larynx  than  from  the  en- 
tire internal  surface  of  the  lungs,  an  observation 
that  strongly  implies  a role  of  the  larynx  as  a 
sensory  organ.  This  internal  branch  appears  to 
be  important  in  regulating  swallowing,  breath- 
ing, and  speech  through  short  reflex  connections 
to  the  respiratory  centers  of  the  reticular  forma- 
tion and  the  vagal  motor  nucleus.  Baroreceptors 
responding  to  negative  airway  pressure  have 
profound  effects  on  breathing  patterns.  Flow 
receptors  detect  inspiratory  flow  by  sensing  a 
temperature  drop  in  inspired  air.  Drive  recep- 
tors respond  to  vocal  fold  movement  and  may 
be  important  in  proprioception.7 

The  external  branch  of  the  superior  laryn- 
geal nerve  is  responsible  for  motor  innervation 
of  the  inferior  pharyngeal  constrictors  and  the 
single  intrinsic  muscle  of  the  larynx  not  inner- 
vated by  the  recurrent  laryngeal  nerve,  the  cri- 
cothyroid muscle.  The  cricothyroid  is  both  a ten- 
sor and  adductor  of  the  vocal  cords  and  also  sta- 
bilizes the  larynx  during  abduction. 

The  external  branch  of  the  superior  laryn- 
geal nerve  has  been  found  to  have  considerable 
variation  in  its  course  in  relation  to  the  superior 
laryngeal  artery  and  the  superior  thyroid 
pedicle.  Cernea8  has  made  an  effort  to  classify 
these  variations  according  to  the  nerve's  risk  of 
injury  during  thyroidectomy.  He  described  the 
variations  as:  type  I,  the  most  common,  in  which 
the  nerve  runs  superior  to  the  thyroid  pedicle 
and  is  clearly  visible  during  surgical  dissection; 
type  Ha,  in  which  the  nerve  lies  on  the  surface 
or  marginally  within  the  capsule  of  the  thyroid 
pedicle  and  is  at  moderate  risk  when  the  thy- 
roid tissue  is  excised;  and  type  Hb,  in  which  the 
nerve  plunges  deep  to  the  thyroid  pedicle  and 
often  wraps  around  the  branches  of  the  supe- 
rior thyroid  artery.  The  type  lib  variation  has  the 
highest  surgical  risk  because  it  is  most  often  in- 


jured during  ligation  of  the  artery.  A 
nonrandomized  prospective  study  by  Cernea  et 
al  found  that  the  variation  is  found  in  14%  to 
20%  of  persons  with  normal  to  slightly  enlarged 
thyroid  glands  and  in  greater  than  50%  in  pa- 
tients with  large  (>400  gram)  goiters.9 

CLINICAL  MANIFESTATIONS 

Loss  of  voice  or  aspiration  difficulties  are  com- 
mon complications  after  thyroid  surgery,  in 
some  studies  as  high  as  11%  to  25%. 10  Most  of 
these  symptoms  can  be  attributed  to  post-intu- 
bation injury  or  soft  tissue  swelling,  which  re- 
solves in  days  to  weeks.  Superior  laryngeal 
nerve  injury  has  different  manifestations  de- 
pending on  whether  the  injury  occurs  to  the  ex- 
ternal or  internal  branches.  Sudden  interruption 
of  the  sensory  supply  to  the  supraglottic  larynx 
can  lead  to  temporary  difficulty  with  aspiration 
and  choking  spells.  Normal  secretions  accumu- 
late that  would  otherwise  be  cleared  by  reflex 
swallowing,  throat  clearing,  or  cough.  Sudden 
spillover  into  the  subglottic  area,  where  sensory 
innervation  is  mediated  via  the  intact  recurrent 
laryngeal  nerve,  causes  sudden,  paroxysmal 
coughing.  Incomplete  or  recovering  sensory  loss 
can  also  produce  paresthesias,  which  may  be  in- 
terpreted symptomatically  as  a vague  discom- 
fort or  the  presence  of  secretions  needing  to  be 
cleared.  With  bilateral  sensory  loss,  an  unusual 
occurrence,  aspiration  is  very  problematic  ini- 
tially, and  often  requires  some  form  of  interven- 
tion. In  either  case  compensation  almost  always 
develops  within  weeks  to  months.11 

Injury  to  the  external  branch  can  lead  to  sig- 
nificant voice  changes  and  tends  to  be  the  most 
persistent  complaint  of  patients.  The  loss  of  the 
upper  voice  register  is  a rather  selective  sign  in- 
dicative of  dysfunction  of  the  cricothyroid 
muscle.  Lack  of  cord  tension  leads  to  balloon- 
ing of  the  cords  in  a superior  direction  during 
phonation.  This  action  prevents  effective  glottic 
closure  and  produces  a drop  in  voice  pitch,  a 
phenomenon  especially  noticeable  in  females. 
Symptoms  include  constant  throat  clearing  and 
a slightly  breathy  voice.  The  voice  often  is  weak 


144  J La  State  Med  Soc  VOL  152  April  2000 


and  lacks  power  and  resonance.  Other  symp- 
toms can  include  monotonic  speech  or 
diplophonia  (the  simultaneous  sounding  of  two 
pitches),  especially  in  the  higher  pitches  of  the 
voice  or  when  trying  to  sing.  The  ability  to  raise 
or  maintain  the  pitch  of  the  voice  is  almost  im- 
possible and  air  wasting  is  prominent,  resulting 
in  shortened  phonation  time. 

The  symptoms  associated  with  superior  la- 
ryngeal nerve  paralysis  vary  widely.  The  factors 
altering  the  degree  of  dysfunction  include:  (1) 
the  shape  of  the  glottis;  (2)  differences  in  the  rela- 
tive levels  of  the  vocal  cords;  (3)  the  presence  of 
permanent  structural  changes;  (4)  the  position 
of  the  arytenoids;  (5)  the  degree  of  compensa- 
tion exercised  by  the  patient;  (6)  whether  paraly- 
sis is  unilateral  or  bilateral;  and  (7)  the  position 
of  the  vocal  cord.  Clinical  manifestations  of  pa- 
ralysis vary  depending  on  cord  position,  and  this 
is  the  most  important  single  factor.12 

DIAGNOSIS 

When  the  sensory  branch  is  injured,  anesthesia 
of  the  ipsilateral  larynx  can  be  demonstrated  by 
direct  palpation  with  a probe  while  noting  the 
absence  of  reflex  responses.  Absence  of  reflex 
response  is  an  indication  of  sensory  paralysis. 
The  involved  hemilarynx  may  appear  injected 
secondary  to  vasodilation  resulting  from  loss  of 
sympathetic  nerve  supply,  although  simulta- 
neous destruction  of  the  superior  laryngeal  ar- 
tery prevents  hyperemia. 

Recognition  of  the  subtle  symptoms  of  ex- 
ternal branch  SLN  injury  can  be  confirmed  by 
objective  tests  of  laryngeal  function.  Manipula- 
tion tests  may  help  in  the  diagnosis  of  bilateral 
as  well  as  unilateral  paralysis.  Frontal  pressure 
on  the  thyroid  cartilage  (Guttmann's  test)  will 
normally  lower  voice  pitch  by  counteracting  cri- 
cothyroid function,  whereas  lateral  pressure  has 
the  opposite  effect.  No  response  to  manipula- 
tion suggests  cricothyroid  paralysis.  Failure  of 
the  cricothyroid  space  to  narrow  on  phonation 
may  be  noted  on  palpation  or  serial  radiographs. 
Manual  compression  of  this  space  will  raise  the 
voice  pitch  when  paralysis  is  present.  EMG  is 


the  gold  standard  of  diagnosis  and  is  of  value 
due  to  its  excellent  sensitivity  and  specificity,  low 
cost,  and  the  accessibility  of  the  cricothyroid 
muscle. 

The  most  distinct  features  of  an  isolated 
single  cricothyroid  muscle  paralysis  can  be 
monitored  with  indirect  or  direct  laryngoscopy, 
although  findings  are  subtle  (Figure  2).  The  pa- 
tient must  be  asked  to  phonate  at  a relatively 
high  pitch,  since  the  muscle  is  most  active  at  this 
time.  Contraction  of  the  cricothyroid  muscle  on 
the  unaffected  side  causes  rotation  of  the  cricoid 
cartilage  against  the  thyroid  cartilage.  The  pos- 
terior commissure  deviates  toward  the  para- 
lyzed side  producing  an  oblique  glottis.  The 
vocal  cord  on  the  paralyzed  side  appears  bowed, 
short,  and  bulky  with  a wavy  appearance  due 
to  the  unopposed  action  of  the  thyroarytenoid 
muscle.  The  vocal  cord  is  usually  noted  to  lie  at 
a more  inferior  level  than  the  cord  on  the  para- 
lyzed side  because  of  the  tilting  of  the  cricoid 
and  displacement  of  the  flaccid  cord  by  air  cur- 
rents.13 


I.  II. 

Figure  2.  I.  Normal  larynx  as  seen  by  laryngoscopy. 
II.  Unilateral  superior  laryngeal  nerve  paralysis  showing 
posterior  commisure  deviated  toward  the  side  of  the 
paralysis. 

Since  Mygind  first  described  the  oblique  glottis 
in  1906  in  patients  with  unilateral  SLN  paraly- 
sis, the  subject  has  remained  controversial.  While 
some  laryngologists  report  similar  findings,14 
others  have  reported  that  they  rarely  observe  an 
oblique  glottis.2'14  In  a recent  attempt  to  explain 
the  possible  reasons  why  visual  findings  have 
been  variable,  Tanaka  et  al15  proposed  that  the 


J La  State  Med  Soc  VOL  152  April  2000  145 


degree  of  obliquity  depends  on  the  strength  of 
the  contraction  of  the  cricothyroid  muscle, 
which  is  greatest  in  the  high  range  of  the  voice, 
and  therefore  weak  contraction  will  elicit  mini- 
mal endoscopic  findings.  Tanaka  concluded 
that  observing  the  glottis  while  the  patient  pro- 
duces a low-pitched  phonation  followed  by  a 
high-pitched  phonation  is  a relatively  simple 
and  accurate  diagnostic  procedure  to  test  for 
unilateral  SLN  paralysis. 

TREATMENT 

Internal  nerve 

No  specific  treatment  is  usually  required  for 
isolated  unilateral  sensory  paralysis.  Bilateral 
sensory  paralysis  may  cause  considerable  dys- 
phagia and  aspiration,  but  most  patients  will 
compensate  for  this  deficit,  as  can  be  demon- 
strated in  patients  who  have  had  both  the 
nerves  removed  in  the  process  of  a supraglot- 
tic  subtotal  laryngectomy.  More  serious  prob- 
lems arise  when  the  sensory  deficit  is  combined 
with  laryngeal  motor  paralysis.  Treatment  in- 
volves reassuring  the  patient  and  reestablish- 
ing swallowing  habits. 

External  Nerve 

With  a lesion  of  the  external  nerve,  correction 
of  vocal  abnormalities  is  the  main  goal  of 
therapy.  However,  unlike  unilateral  paralysis 
of  the  recurrent  nerve,  which  may  be  compen- 
sated for  by  overaction  of  the  opposite  vocal 
cord,  the  symptoms  of  unilateral  cricothyroid 
muscle  paralysis  are  made  worse  by  overaction. 
Successful  vocal  therapy  is  dependent  on  early 
recognition  of  the  injury,  because  incorrect  com- 
pensatory mechanisms  are  difficult  to  correct. 
Therapy  should  be  based  upon  relaxation  of 
the  functioning  cricothyroid  muscle  during 
phonation.16  In  some  cases  it  is  possible  that  no 
therapy  is  necessary  once  the  situation  is  ex- 
plained to  the  patient,  as  most  will  have  a voice 
satisfactory  for  everyday  needs. 

Surgery  is  a rare  treatment  option  for  this 
injury,  and  is  only  attempted  in  the  most  de- 


manding cases.  May  et  al17  have  attempted  rein- 
nervation of  the  cricothyroideous  muscle  by 
nerve-muscle  pedical  technique  with  satisfac- 
tory results.  A surgical  procedure  to  narrow  the 
cricothyroid  space  may  be  of  benefit  if  symp- 
toms are  severe.  An  anterior  commissure  ad- 
vancement technique  has  been  described  by 
Lejeune18  and  Tucker.5  Thompson  has  used  a 
technique  of  cricothyroid  approximation  by  su- 
turing the  thyroid  to  the  cricoid  cartilage  to  el- 
evate the  cartilage  during  phonation.19 

CONCLUSION 

Superior  laryngeal  nerve  injury  is  a common  and 
preventable  complication  of  thyroid  surgery.  The 
injury  is  recognizable  with  careful  attention  to 
subjective  complaints,  laryngoscopic  examina- 
tion, and  in  the  most  elusive  cases,  electromyo- 
graphy. An  emphasis  on  prevention  is  impor- 
tant because  of  the  limited  operative  treatment 
options  that  can  be  offered.  It  is  also  important 
to  remember  that 

(a)  early  diagnosis  can  lead  to  appropriate  vo- 
cal therapy  intervention,  and  can  substan- 
tially reduce  chronic  voice  dysfunction  in 
post-surgical  patients; 

(b)  incidence  of  surgically  related  injury  is  likely 
higher  than  once  thought,  and  is  avoidable 
with  careful  dissection  technique; 

(c)  the  aberrance  rate  (type  lib  nerve)  of  the  su- 
perior laryngeal  nerve  is  high.  The  increased 
surgical  risk  to  patients  with  large  goiters 
should  be  recognized;  and 

(d)  patients  having  a career  with  demanding 
laryngeal  requirements  (singers,  actors,  ora- 
tors, lawyers,  teachers,  etc.)  can  potentially 
be  seriously  affected  by  an  injury  to  the  su- 
perior nerve. 

The  most  famous  case  of  superior  laryngeal 
nerve  injury  occurred  at  the  turn  of  the  century 
with  the  celebrated  opera  voice  of  that  age,  the 
coloratura  soprano  Madame  Amelita  Galli- 
Curci.  Over  a period  of  fifteen  years,  a progres- 
sively enlarging  thyroid  threatened  her  career, 
and  in  1935  she  elected  to  have  her  thyroid  re- 
moved in  Chicago.  The  procedure  was  done 


146  J La  State  Med  Soc  VOL  152  April  2000 


under  local  anesthesia,  and  the  patient  trilled 
throughout  the  operation  to  confirm  the  integ- 
rity of  the  recurrent  laryngeal  nerves.  However, 
after  the  procedure  the  singer 's  upper  vocal  reg- 
ister had  fallen  substantially  to  that  of  a lyric 
soprano  and  had  lost  its  vitality  One  critic  wrote 
"the  amazing  voice  is  gone  forever,  instead  of 
cream  velvet  there  is  a sad  quivering  ghost."1-  It 
is  important  to  remember  that  for  those  that  have 
made  their  voice  an  important  part  of  their  ca- 
reer, this  injurv  can  be  devastating. 

REFERENCES 

1.  Crumley  RL.  Repair  of  the  recurrent  larvngeal 
nerve.  Otolaryngol  Clin  North  Ain  1990;23:553-563. 

2.  Bevan  K,  Griffiths  MV,  Morgan  MH.  Cricothyroid 
muscle  paralysis:  its  recognition  and  diagnosis. 
Laryngol  Otol  1989;103:191-195. 

3.  Tucker  HM.  The  Larynx.  New  York,  NY:  Thieme 
Med  Publishers;  1987:235-239. 

4.  Teitelbaum  BT,  Wenig  BL.  Superior  laryngeal  nerve 
injury  from  thyroid  surgery.  Head  Neck  1995;  17:36- 
40. 

5.  Tucker  HM.  Vocal  cord  paralvsis-1979:  etiology  and 
management.  Laryngoscope  1980;90:585-590. 

6.  Kark  AK,  Kissin  MW.  Superior  laryngeal  nerve  in- 
tun'. Head  Neck  1995;17:542-543. 

7.  Woodson  GE.  Lanmgeal  neurophysiology  and  its 
clinical  uses.  Head  Neck  1996;18:78-86. 

8.  Cemea  CR,  Ferraz  AR,  Furlani  J,  et  al.  Identifica- 
tion of  the  external  branch  of  the  superior  lanm- 
geal  nene  during  thyroidectomy.  Am  J Surg  1992; 
164:634-639. 

9.  Cemea  CRr  Xishio  S.  Identification  of  the  external 
branch  of  the  superior  lanmgeal  newe  iEBSLX  i in 
large  goiters.  Am  J Otolaryngol  1995;16:307-311. 

10.  Kark  AK,  Kissin  MW,  Auerbach  R,  et  al.  Voice 
changes  after  thyroidectomy:  role  of  the  external 
laryngeal  nenrn.  Br  Med  J 1984;289:1412-1415. 


11.  Fried  MP.  Tr.e  Larynx:  A Multidisciplinarj  Approach. 
Boston:  Little  Brown;  1988:1-23. 

12.  Ballenger  JJ.  Diseases  of  ike  Nose,  Throat.  Ear.  Head 
ana.  Neck.  Philadelphia,  Pa:  Lea  and  Febiger; 
1991:656-663. 

13.  Yin  SS,  Qiu  WW,  Stucker  FJ,  et  al.  Evaluation  of 
bilateral  vocal  fold  dysfunction:  paralysis  versus 
fixation,  superior  versus  recurrent,  and  distal  ver- 
sus proximal  to  the  larvngeal  nerves.  Am  J 
Otolaryngol  1997;18:9-18. 

14.  Abelson  TL  Tucker  HM.  Lanmgeal  findings  in  su- 
perior lanmgeal  nene  paralysis:  a controversy. 
Otolaryngol  Head  Neck  Surg  1981;  89:463-470. 

15.  Tanaka  S,  Hirano  M,  Umeno  H.  Lanmgeal  behav- 
ior in  unilateral  superior  lanmgeal  nen  e paraly- 
sis. Ann  Otol  Rhinol  Laryngol  1994;103:93-97. 

16.  Dursun  G,  Sataloff  RT,  Spiegel  JR,  et  al.  Superior 
lanmgeal  nerve  paresis  and  paralysis.  J Voice 
1996;10:206-211. 

17.  Mav  M.  Rehabilitation  of  the  crippled  laxymx:  ap- 
plication of  the  Tucker  technique  for  muscle-nen~e 
reimnen  ation.  Laryngoscope  1980;90:1-18. 

15.  LeTeune  FE.  Guice  CE,  Samuels  PM.  et  al.  Early  ex- 
periences with  vocal  ligament  tightening.  Ann  Otol 
Rhinol  Laryngol  1983;92:475-477. 

19.  Thompson  JW,  Ward  PH.  Schwartz  FR.  Experimen- 
tal studies  for  correction  of  superior  lanmgeal  nene 
paralysis  by  fusion  of  the  thyroid  to  cricoid 
cartilages.  Otolaryngol  Head  Neck  Surg  1984:92:498- 
508. 


Dr  Schaffer  is  a resident  physician  with  the 
Department  of  Otolaryngology  at 
Tulane  University  School  of  Medicine. 

Nezc  Orleans , Louisiana. 

Dr  Ante  dee  is  Professor  and  Chairman  at  the 
Department  of  Otolaryngology.  Head  and  Neck  Surgery. 

Tulane  University  School  of  Medicine, 
New  Orleans.  Louisiana. 


Table.  Incidence  of  superior  laryngea'  nerve  injury  by  various  authors  after  thyroid  surgery  and  methods  used  to 
obtain  diagnosis. 


Author 

No.  of  patients 

Incidence  % 

Methods 

Lore  et  al  (1977)4 

111 

.9 

Indirect  Laryngoscopy 

Rossi  et  al  (1986)" 

309 

not  mentioned 

Lennquist  et  al  (1987)" 

38 

2.6 

Indirect  Laryngoscopy 

Lekacos  et  al  (1987)  4 

149 

0-11 

Indirect  Laryngoscopy 

Jansson  et  al  (1988)" 

20 

58 

EMG 

Cemea  et  al  (1988) 4 

76 

0-28 

EMG . acoustics 

Teitelbaum  et  al  (1995 ) 4 

26 

5 

EMG . videostroboscopy,  subjective  intemew 

J La  State  Med  Soc  VOL  "52  Apnl  2000  147 




— - _ . _ - . . ____ 


Lower  Extremity  Bruit 

Sanjay  M.  Patel,  MD;  Harold  Neitzschman,  MD;  and  Joseph  Higgins  Jr,  MD,  PhD 


A 59-year-old  man  was  involved  in  a roll-over  motor  vehicle  accident.  On  examination  a bruit 
was  heard  in  the  left  popliteal  fossa. 


Map  S 

DynRg  30dS 
Persist  Med 
Fr  Rate  Mad 


LLE 


Col  78%  Map  1 
WF  Low 
PRF  lOOOOHl 


♦ rr.  i 

i. 


St  SB 


t T PAP  PSAV  «< 

OTHER  PRIOR 


SV  Angle  SO 
Dep  32  ci 
Size  1 .5  mi 
Freq  4.0  MHz 
WF  Low 
Dop  78%  Ma| 
PRF  14Z8SH2] 


-3J 

~ZJ 

-1J 

1J 


IMAGE 


Figure  la.  Duplex  examination  of  the  left  superficial 
left  popliteal  artery. 


Figure  1b.  Duplex  examination  of  the  femoral  artery 
and  vein. 


148  J La  State  Med  Soc  VOL  152  April  2000 


Figure  1c.  Duplex  examination  of  the  popliteal  fossa.  Figure  Id.  Duplex  examination  left  mid  superficial 

femoral  vein. 


Figures  2a  and  2b.  Left  lower  extremity  angiogram. 


What  is  your  diagnosis? 
Elucidation  is  on  page  150. 


J La  State  Med  Soc  VOL  152  April  2000  149 


Radiology  Case  of  the  Month 
Case  Presentation  begins  on  page  148. 

RADIOLOGIC  DIAGNOSIS  - Popliteal 
arterior-venous  malformation 

PATHOLOGIC  DIAGNOSIS  - Same 

INTERPRETATION  OF  IMAGES 

Axial  image  of  the  femoral  artery  and  vein  dem- 
onstrates that  both  lumens  are  prominent  (Fig- 
ure la).  Sonographic  evaluation  through  the 
popliteal  artery  demonstrates  loss  of  normal 
triphasic  waveform  and  presence  of  a low  resis- 
tance waveform  (Figure  lb).  Mosaic  pattern  of 
flow  is  seen  in  the  popliteal  fossa  (Figure  lc). 
There  is  increased  velocity  in  the  mid  superficial 
femoral  vein  and  pulsatility  of  the  venous  wave- 
form (Figure  Id).  Left  lower  extremity  arterio- 
gram shows  enlargement  of  the  left  external  iliac, 
common  femoral,  superficial  femoral,  and 
popliteal  arteries.  Multiple  collateral  vessels  are 
seen  in  the  popliteal  fossa.  The  draining  superfi- 
cial femoral  vein  is  enlarged  (Figures  2a, b). 

DISCUSSION 

Vascular  malformations  are  structural  anomalies 
resulting  from  inborn  errors  of  vasculomorph- 
ogenesis.  The  lesions  are  present  at  birth.  Trauma, 
surgery,  hormonal  influences  caused  by  birth 
control  pills,  and  hormonal  changes  during  pu- 
berty and  pregnancy  may  cause  lesions  to  en- 
large.1 

Vascular  malformations  are  endothelial-lined 
vascular  channels.  The  endothelium  does  not 
demonstrate  proliferation.  They  may  be  formed 
from  any  combination  of  primitive  arterial,  cap- 
illary, venous,  or  lymphatic  elements  with  or 
without  arterio-venous  shunts. 

Arteriovenous  communications  may  be  ac- 
quired or  congenital.  Acquired  lesions  are  usu- 
ally iatrogenic,  although  spontaneous  communi- 
cations may  occur  with  tumors.  Most  acquired 
lesions  occur  with  a single  dominant  feeding  ar- 
tery and  a single  dominant  draining  vein.2  Con- 
genital malformations  consist  of  a tangle  of  small 
abnormal  vessels. 


Color  Doppler  imaging  is  useful  in  the 
workup  of  vascular  malformations.  High-flow 
lesions  (AVMs,  AVF)  and  low-flow  lesions 
(venous  malformation,  lymphatic  malformation) 
can  be  accurately  diagnosed. 

A normal  Duplex  pattern  extremity  arterial 
flow  is  a high  resistance  waveform.  Duplex  scans 
of  the  normal  lower  extremity  show  the  charac- 
teristic triphasic  velocity  waveform  that  is  asso- 
ciated with  peripheral  artery  flow.3  The  initial 
high  velocity,  antegrade  flow  that  results  from 
cardiac  systole  is  followed  by  a brief  period  of 
flow  reversal  in  early  diastole  and  low  velocity 
antegrade  flow  in  late  diastole.4 

Duplex  Doppler  demonstrates  evaluated 
flow  velocity  throughout  diastole  secondary  to 
decreased  resistance  in  the  arterial  limb.  Spec- 
tral broadening  is  present.  Draining  veins  asso- 
ciated with  vascular  malformation  can  be  iden- 
tified by  pulsatile  flow  and  lack  of  flow  alter- 
ation by  Valsalva  maneuver.  Color  Doppler  may 
demonstrate  a tangle  of  tortuous  vessels  with 
multiple  colors  indicative  of  haphazard  orienta- 
tion and  turbulent  flow  within  the  malformation. 

REFERENCES 

1.  Yakes  WF.  Diagnosis  and  management  of  vascu- 
lar anomalies.  Interventional  Radiology.  Baltimore, 
Md:  WR  Castaneda-Zuniga;  1997:103-108. 

2.  Thurston  W,  Wilson  SR.  Diagnostic  Ultrasound.  St 
Louis,  Mo:  C.M.  Rumack;  1998;329-397. 

3.  Blackshear  WM,  Phillips  DJ,  Strandness  DE  Jr. 
Pulsed  Doppler  assessment  of  normal  human 
femoral  artery  velocity  patterns.  J Surg  Res 
1979;27:73-83. 

4.  Zierler  RE,  Zierler  BK.  Introduction  to  Vascular  Ul- 
trasonography. Philadelphia,  Pa:  WJ  Zwiebel; 
1992:237-251. 


Dr  Patel  is  a senior  resident  at 
Louisiana  State  University  Health  Sciences  Center  in 

New  Orleans , Louisiana. 

Dr  Neitzschman  is  an  associate  professor  of  radiology 
and  orthopaedics  at  Louisiana  State  University 
Health  Sciences  Center  in  New  Orleans,  Louisiana. 

Dr  Higgins  is  an  assistant  professor  of  radiology 
at  Louisiana  State  University 
in  Baton  Rouge,  Louisiana. 


150  J La  State  Med  Soc  VOL  152  April  2000 


History  of  Medicine 


Frontal  Lobe  Damage  and 
The  Case  of  Phineas  Gage 


James  F.  Martin,  BS  and  Hector  0.  Ventura,  MD 


Presented  in  part  at  the  annual  meeting  of  the 
Tulane  History  of  Medicine  Society , April  1999. 
This  work  was  the  recipient  of  the  "Isaac  Ivan 
Lemann  Award"  given  by  the  Tulane  History 
of  Medicine  Society. 

On  September  13th,  1848,  a tremendous 
accident  befell  a worker  on  a railroad 
gang  in  Cavendish,  Vermont,  near  the 
Rutland  and  Burlington  Railway.  Phineas  P. 
Gage,  a 25-year-old  youth  of  Lebanon,  New 
Hampshire,  was  of  sound  mind  and  body  on 
the  morning  of  the  accident.  As  Gage  was 
tamping  a charge  into  a hole  in  the  rock,  sparks 
ignited  the  powder,  driving  the  tamping  rod  up, 
through  his  head,  and  much  distance  behind 
him.  Before  the  accident,  Phineas  Gage  was 
described  as  having  perfect  health,  strong  and 


active,  possessing  an  iron  will.  He  was  5 feet,  6 
inches  tall,  ’weighing  roughly  150  pounds.  He 
was  extraordinarily  well  muscled  and  was 
described  as  hardly  ever  ill. 

Gage  was  the  foreman  for  his  crew.  As  a 
description  of  his  temperament,  it  was  offered 
that  he  was  the  favorite  of  the  men,  and  his 
employers  regarded  him  as  the  most  capable  and 
efficient  foreman  they  had  ever  had.  He  was 
described  by  those  who  knew  him  as  "a  shrewd, 
smart  businessman,  very  energetic  and 
persistent  in  executing  all  his  plans  of 
operation".1  This  was,  of  course,  until  the 
accident. 

The  tamping  iron  entered  Gage's  face  on  the 
left  side,  under  the  zvgomatic  bone  and  anterior 
to  the  angle  of  the  jaw.  The  rod  passed  obliquely 
upwards  and  backwards,  passed  under  the 


J La  State  Med  Soc  VOL  152  Acr  2000  151 


junction  of  the  superior  maxillary  and  malar 
bones,  emerging  in  the  median  line  of  the  skull 
at  the  back  of  the  frontal  bone,  near  the  coronal 
suture.  The  bones  that  were  affected  by  the  rod's 
passage  were  the  superior  maxillary,  malar, 
sphenoid,  and  frontal.  The  exit  wound  was  a hole 
in  the  top  of  the  head;  an  oblong  and  irregular 
gap  2 inches  by  3 and  1/2  inches.  The  frontal 
lobe  of  the  skull  was  extensively  fractured,  and 
there  were  vast  amounts  of  blood  and  pulverized 
brain  tissue. 

Gage  was  thrown  back  onto  the  ground, 
where  he  suffered  a few  convulsions,  but  was 
able  to  speak  within  a few  minutes.  His  men 
lifted  and  carried  him  a few  rods  to  the  road, 
where  he  was  loaded  into  an  ox-cart  (a  different 
account  states  that  he  was  writing  in  his  work 
book  within  minutes  of  the  accident2).  Supported 
in  a sitting  position  in  the  ox-cart,  Phineas  was 
driven  3/4  of  a mile  to  his  hotel  where  he  was 
able  to  climb  out  of  the  cart  by  himself,  with 
limited  assistance.  Phineas  Gage  then  sat  on  the 
front  porch  of  the  hotel,  awaiting  the  doctor.  By 
the  time  the  doctor  arrived  he  had  already  told 
all  the  bystanders  what  had  happened,  and  on 
the  doctor's  arrival  was  lucid  enough  to  greet 
the  doctor  with  the  statement  "Doctor,  here  is 
business  enough  for  you."  3 An  hour  after  his 
arrival,  he  was  helped  up  a 'Tong  flight  of  stairs"1 
to  his  room  where  Dr  Harlow  noted  that  "he 
seemed  perfectly  conscious"  upon  examination. 
Gage  did  however  suffer  some  misfortune  in  that 
he  was  very  weak  from  tremendous  blood  loss 
(noted  to  be  freely  flowing  from  his  lacerated 
sinus),  and  he  would  retch  violently  every  15  to 
20  minutes  due  to  blood  dribbling  into  his 
stomach. 

As  the  primary  examiner.  Dr  Harlow  gives 
accurate  accounts  of  Gage  because  he  suspected 
how  much  disbelief  this  case  would  hold  in  the 
medical  field.  He  stated  that  Phineas  "bore  his 
sufferings  with  firmness"  and  that  Gage  told  him 
himself,  while  pointing,  "the  iron  entered  there 
and  passed  through  my  head."  At  the  time  Gage 
related  this  knowledge,  the  doctor  took  his  pulse 
to  be  60,  and  described  it  as  "soft  and  regular".1 


Dr  Harlow,  assisted  by  the  other  town  doctor. 
Dr  Williams,  dressed  the  wound.  It  is  stated  in 
their  report  that  bone  fragments  were  removed 
from  the  top  of  the  head,  uncovering  the  brain 
that  could  be  seen  and  felt  to  pulse  and  quiver. 
Because  of  the  shape  of  the  wound,  the  doctors 
were  able  to  see  that  the  wound  was  caused  from 
below,  with  the  bone  around  the  wounds  pushed 
outwards,  resembling  an  "inverted  funnel". 

The  wound  continued  to  bleed  for  a couple 
of  days,  and,  just  as  it  seemed  like  Phineas  would 
recover,  he  became  violently  ill  with  a viral 
infection  and  fell  unconscious  for  about  a month. 
His  condition  deteriorated  so  much  that  there 
was  a coffin  prepared  for  him.  However,  with 
continued  medical  treatment,  during  the  fifth 
week  after  the  accident,  the  infection  subsided.2 

The  following  April,  nearly  7 months  after 
the  accident.  Gage  returned  to  see  Dr  Harlow, 
who  in  turn  did  a check  up  on  Gage.  He 
described  his  general  appearance  as  good: 

(Gage)  stands  quite  erect,  with  his  head 
inclined  slightly  towards  the  right  side;  his 
gait  in  walking  is  steady;  his  movements 
rapid  and  easily  executed.  The  left  side  of 
his  face  is  wider  than  the  right  side,  the  left 
malar  bone  being  more  prominent  than  its 
fellow.  There  is  a linear  cicatrix  (scar)  near 
the  angle  of  the  lower  jaw,  an  inch  in  length, 
ptosis  of  the  left  eyelid;  the  globe 
considerably  more  prominent  than  its  fellow, 
but  not  as  large  as  when  I last  saw  him.  Can 
abduct  and  depress  the  globe,  but  can  not 
move  it  in  other  directions  . . . partial 
paralysis  of  the  left  side  of  his  face.  His 
physical  health  is  good,  and  I am  inclined  to 
say  that  he  has  recovered.  Has  no  pain  in 
head,  but  says  it  has  a queer  feeling  which 
he  is  not  able  to  describe.1 

These  facts  lend  to  the  belief  that  motor 
coordination  and  vital  functioning  occur  in  the 
lower  brain  which,  for  Mr  Gage,  were 
unaffected.  For  all  intents  and  purposes,  Mr 
Phineas  P Gage  seemed  to  have  fully  recovered. 


152  J La  State  Med  Soc  VOL  152  April  2000 


Although  all  physical  attributes  seemed  normal 
(other  than  the  slight  slant  of  the  head),  Phineas 
Gage's  mental  processes  and  emotions  were 
affected.  Mr  Gage  tried  to  regain  his  previous 
work  with  the  contractors  that  he  had  so 
successfully  completed  jobs  for  in  the  past. 
However,  in  the  most  clear  account  of  his 
personality  change,  they  would  not  hire  him 
back  due  to  the  fact  that  "the  equilibrium  or 
balance,  so  to  speak,  between  his  intellectual 
faculties  and  animal  propensities,  seem  (ed)  to 
have  been  destroyed".14  His  employers  went  on 
to  describe  him  as  now  fitful,  irreverent,  profane 
in  his  language,  showing  no  difference  for  his 
fellows,  impatient,  and  obstinate.  They  told  of 
how  he  would  devise  plans  for  the  future  that 
"are  no  sooner  arranged  than  are  abandoned  in 
turn  for  others  appearing  more  feasible".  This 
was  directly  antagonistic  to  the  way  that  they 
had  described  him  previous  to  the  accident.  It 
was  so  bad  that,  his  past  employers  went  so  far 
as  to  state  that  he  was  "no  longer  Gage".12 

Dr  Harlow  himself  stated  about  his  patient 
that  he: 

Remembers  passing  and  past  events 
correctly , as  well  before  as  since  the  injury. 
Intellectual  manifestations  feeble , being 
exceedingly  capricious  and  childish , but 
with  a will  as  indomitable  as  ever;  is 
particularly  obstinate;  will  not  yield  to 
restraint  when  it  conflicts  with  his  desires.2 

To  make  matters  worse,  his  mother  described 
to  Dr  Harlow3  how  he  would  entertain  his  nieces 
and  nephews  with  made  up  stories.  He  would 
describe  "his  wonderful  feats  and  hairbreadth 
escapes,  without  any  foundation  except  in  his 
fantasy."3  Mr  Gage  had  led  a somewhat 
uneventful  life;  somehow  the  damage  to  his 
brain  had  rendered  him  apt  to  make  up 
outrageous  stories.  The  other  interesting 
development  of  the  tragedy  was  Mr  Gage's  new 
found  fondness  of  animals  — never  before  was 
he  much  of  an  animal  lover,  but  soon  after  the 
accident,  he  developed  a pronounced  at- 
tachment to  animals. 


These  remarks  by  Dr  Harlow  are  the  extent 
of  what  we  know  of  Mr  Gage's  psychological 
changes.  So,  what  happened  to  Mr.  Gage? 
Phineas  Gage  took  to  traveling,  with  of  course 
his  beloved  tamping  iron  by  his  side.  It  is 
documented  that  he  visited  Boston,  as  well  as 
the  other  large  New  England  towns,  and  New 
York.  He  stayed  for  a while  in  New  York  and 
took  part  in  Barnum's  freak  show,  accompanied 
by  his  tamping  iron.  In  1851,  he  took  a job  with 
a Mr  Jonathan  Currier,  from  Hanover,  New 
Hampshire,  for  which  he  worked  in  Mr  Currier's 
livery  stable.  He  remained  in  this  position  for  a 
year  and  a half  until  August  of  1852,  when  he 
took  a new  job  with  a man  headed  for  Chile. 
While  in  Chile  he  was  to  establish  a line  of 
coaches  at  Valparaiso.  He  remained  in  Chile,  in 
the  vicinity  of  Valparaiso  and  Santiago,  nearly  8 
years  until  1860.  He  cared  for  horses,  drove 
coaches  often  lead  by  six  horses,  and  otherwise 
stayed  occupied  until  his  health  began  to  fail. 
After  a long  illness  from  which  he  never  fully 
recovered,  he  developed  epilepsy,  and  in  1860 
he  left  Chile  for  San  Francisco  to  be  reunited  with 
his  mother  and  sister. 

After  his  arrival  in  San  Francisco  his  health 
improved,  and  he  took  work  as  a farmer  in  Santa 
Clara,  but  he  did  not  stay  in  this  capacity  long. 
In  February  1861,  he  was  documented  as  falling 
ill  with  a "fit",  which  was  followed  by  many 
more  in  succession.  Two  days  later,  at  5 am  on 
the  20th,  Mr  Gage  had  a severe  convulsion,  for 
which  he  was  bled.  The  convulsions  continued 
for  the  next  day  and  following  night  and  at  10 
pm  on  May  21st,  1861  - 12  years,  6 months,  and 
8 days  after  his  famous  accident  — Phineas  Gage 
died  of  status  epilepticus.  After  the  death.  Dr 
Harlow  stated  that: 

. ..mentally  the  recovery  certainly  was  only 
partial , his  intellectual  faculties  being 
decidedly  impaired,  but  not  totally  lost; 
nothing  like  dementia,  but  they  were 
enfeebled  in  their  manifestations,  his  mental 
operations  being  perfect  in  kind,  but  not  in 
degrees  or  quantity.4 


J La  State  Med  Soc  VOL  152  April  2000  153 


The  medical  society  of  the  time,  anchored  in 
a background  of  phrenology  and  Broca's  ideas 
on  aphemia  (1861),  were  very  reluctant  to  Dr 
Harlow's  hypothesis2.  It  wasn't  until  a decade 
later  that  new  ideas  called  the  Goulstonian 
lectures,  presented  by  David  Ferrier,  offered  the 
conclusion  that  different  regions  of  the  cortex 
have  assignable,  definitive  functions,  and  effects 
of  lesions  will  vary  depending  on  where  they 
are  and  how  extensive5.  These  ideas  of  Ferrier's 
were  based  in  experimental  physiology,  in  which 
he  had  conducted  experiments  involving 
removal  of  the  prefrontal  lobes  of  monkeys.  His 
findings  are  as  follows: 

...removal  or  destruction  by  the  cautery  of 
the  antero-frontal  lobes  is  not  followed  by 
any  definite  physiological  results  . . . And 
yet,  notwithstanding  this  apparent  absence 
of  physiological  symptoms,  I could  perceive 
a very  decided  alteration  in  the  animal's 
character  and  behavior,  while  it  is  difficult 
to  state  in  precise  terms  the  nature  of  the 
change  . . . While  not  actually  deprived  of 
intelligence,  they  had  lost,  to  all  appearance, 
the  faculty  of  the  attentive  and  intelligence 
observation.5 

Ferrier5  stated  that,  since  the  tamping  iron 
had  passed  through  the  prefrontal  region  of  Mr 
Gage,  the  absence  of  paralysis  was  in  harmony 
with  his  physiological  findings. 

As  it  happens,  there  was  no  autopsy  of  the 
body,  but  the  skull  and  the  tamping  iron  have 
been  placed  in  the  Museum  of  the  Medical 
Department  of  Harvard  University.  An 
examination  of  the  skull  revealed  that  the 
accident  did  indeed  involve  the  prefrontal 
region  of  the  brain,  but  the  exact  structures 
affected  are  still  in  question. 

Recently,  Damasio  et  al6  utilized  modern 
imaging  techniques  and  computer  analysis  in 
an  effort  to  determine  the  exact  location  of  the 
lesion.  Photography,  taken  of  the  inside  and 
outside  of  the  skull,  radiography,  computer 
generated  vectoring,  and  three-dimensional 


mapping  were  all  utilized.  The  resulting 
information  indicated  that  the  lesion  probably 
involved  the  anterior  half  of  the  left  orbital 
frontal  cortex  (Brodmann's  cytoarchitectonic 
fields  11  and  12),  the  left  polar  and  anterior 
medial  frontal  cortices  (fields  8-10  and  32),  and 
the  left  anterior-most  aspect  of  the  anterior 
cingulate  gyrus  (field  24).  In  the  right 
hemisphere,  portions  of  the  anterior  and 
medial  orbital  region  (field  12),  the  medial  and 
polar  frontal  cortices  (fields  8-10  and  32),  and 
the  anterior  cingulate  gyrus  (field  24)  were  all 
damaged.6  There  was  significantly  more 
damage  sustained  in  the  white  matter  of  the 
left  hemisphere  than  the  right,  concentrated  in 
the  ventromedial  frontal  region.  However, 
according  to  the  best  guess  of  the  computer, 
the  supplementary  motor  area  (SMA),  the 
frontal  oberculum  (containing  Broca's  Area), 
and  all  regions  outside  the  frontal  lobes  were 
spared6. 

CONCLUSION 

The  frontal  area  of  the  brain  houses  many 
unidentified  functions.  As  can  be  seen  from  the 
data  presented  above,  accidental  damage  done 
to  the  forebrain  may  cause  random  personality 
changes  without  drastically  affecting  the 
physical  health  of  the  patient. 

Variable  personality  changes  can  occur  if 
an  accident  is  incurred  in  this  manner.  For 
Phineas  Gage,  life  would  physically  return  to 
normal,  but  he  would  forever  be  a changed 
man.  Where  once  he  had  been  intelligent,  kind, 
well-liked,  and  socially  adept,  he  now  held  no 
sense  of  responsibility,  and  he  became 
capricious  and  irreverent.  Other  changes  took 
the  form  of  a decreased  completion  of  plans, 
occasional  gross  verbal  profanity,  impatience, 
and  impulsiveness.  Because  of  the  thorough 
documentation  of  the  case,  the  area  of  the  brain 
that  was  affected  can  be  directly  linked  to  some 
sort  of  personal  control  associated  with  these 
mannerisms.  Although  no  direct  correlation 
between  mannerisms  and  brain  localization 
has  been  found,  these  emotions,  in  all 


154  J La  State  Med  Soc  VOL  152  April  2000 


likelihood,  lie  along  the  path  of  the  damage. 

Damasio's  information  pertaining  to  the 
localization  of  the  lesion  indicates  that  the  most 
affected  region  of  the  brain  was  the 
ventromedial  region  of  the  left  hemisphere.  Mr 
Gage,  along  with  12  other  patients  that 
Damasio  had  come  into  contact  with,  all  with 
similar  lesions,  presented  with  a compromised 
ability  to  make  rational  decisions  in  social  and 
personal  matters.  Also,  emotional  functions 
were  impaired  in  these  patients.  Regions  that 
involve  abstract  problem  logic,  calculations, 
and  the  ability  to  call  up  appropriate 
knowledge  and  use  it,  were  all  spared.  These 
data  indicated  that  the  ventromedial  region  of 
the  frontal  lobes  is  involved  in  these  aspects  of 
human  nature6. 

The  debate  of  frontal  brain  damage 
continues  and  has  sprouted  in  to  many 
different  types  of  heated  debates.  One  such 
notable  debate  involved  human  inhibition  and 
involves  such  renowned  physiologists  as  Franz 
Joseph  Gall,  Robert  Young,  Johannes  Muller, 
Marshall  Hall,  David  Ferrier,  Malcolm 
Macmillan,  and  even  Sigmund  Freud." 
Although  there  is  no  definitive  explanation  to 
the  forebrain  nor  an  accurate  map  of  emotions 
located  therein,  there  is  always  hope  for  a better 
understanding  of  the  human  emotional 
physiology. 

REFERENCES 

1.  Harlow  JM.  Recover}-  from  the  passage  of  an 
iron  bar  through  the  head.  History  Psychol 
1993;4:271-281. 

2.  O'Driscoll  K,  Leach  JP.  No  longer  Gage:  an  iron 
bar  through  the  head:  earlv  observations  of 
personality  change  after  injurv  to  the  prefrontal 
cortex.  Br  Med  J 1998;317:1673-1674. 

3.  Macmillan  MB.  A wonderful  journey  through 
skull  and  brains:  the  travels  of  Mr  Gage's 
tamping  iron.  Brain  Cognition  1986;5:  67-107. 

4.  Harlow  JM.  Recovery  of  an  iron  bar  through 
the  head.  Pub  Mass  Med  Soc  1868;2:327-347. 

5.  Ferrier  D.  The  Goulstonian  Lectures  on  the 
localization  of  cerebral  diseases.  Br  Med  J 
1878:443-447. 

6.  Damasio  H,  Grabowski  T,  Frank  R,  et  al.  The 


return  of  Phineas  Gage:  clues  about  the  brain 
from  the  skull  of  a famous  patient.  Science 
1994;264:1102-1105. 

7.  Macmillan  M.  Inhibition  and  the  control  of 
behavior:  from  gall  to  freud  via  Phineas  Gage 
and  the  frontal  lobes.  Brain  Cognition  1992;19:72- 
104. 


Mr  Martin  is  a second  year  medical  student  at  Tulane 
University  in  New  Orleans,  Louisiana. 

Dr  Ventura  is  a clinical  professor  of  medicine  from  the 
Section  of  Cardiology,  Department  of  Medicine, 
Tulane  University  Hospital  and  Clinic 
in  New  Orleans,  Louisiana. 


J La  State  Med  Soc  VOL  152  Apri  2000  155 


LSMS  Re  sident  Secti : n 


Residency  Programs  Cited 
for  Noncompliance 

Jay  Greene,  AMNews  Staff,  American  Medical  News 
Original  publish  date:  March  6,  2000 
Copyrighted  2000 


In  a first-ever  accounting  of  resident  work- 
hour  citations,  the  Accreditation  Council  for 
Graduate  Medical  Education  cited  more 
than  20%  of  residency  programs  in  nine 
specialties  for  noncompliance  with  various 
duty-hour  standards  in  routine  accreditation 
surveys  last  year. 

Not  surprisingly,  29%  or  more  programs  in 
general  surgery,  orthopedic  surgery,  pediatric 
surgery,  colon  and  rectal  surgery  and  internal 
medicine  were  cited.  The  citations  included 
violations  of  standards  for  "excessive"  total 
monthly  work  hours,  working  more  than  seven 
straight  days  or  not  being  "off  call"  at  least  one 
night  every  three  days.  Programs  also  could 
have  been  cited  for  not  having  a written  duty- 
hour  policy. 

Overall,  ACGME  cited  243  of  2,078  programs 
in  27  accredited  specialties,  or  11.7%  of 


programs  surveyed  in  1999,  for  noncompliance 
with  duty-hour  standards.  ACGME  officials, 
who  released  the  report  last  month  (February 
2000),  said  they  thought  citations  had  been 
increasing  over  the  past  three  years. 

"We  are  very  concerned  with  long  work 
hours  and  the  effect  they  may  have  on  patient 
care  and  resident  education,"  said  Marvin  Dunn, 
MD,  ACGME's  director  of  residency  review 
committee  activities.  "This  [report]  shows  RRCs 
are  citing  programs  when  they  are  out  of 
compliance." 

Residents,  several  program  directors  and 
AMA  officials  said  they  were  not  surprised  by 
the  findings.  Previous  studies  have  found  that 
some  residents  work  more  than  80  hours  per  week. 
State  health  department  inspectors  in  New  York, 
the  only  state  that  limits  work  hours,  found  some 
residents  working  more  than  100  hours  a week. 


156  J La  State  Med  Soc  VOL  152  April  2000 


The  ACGME  report  is  especially  timely  as 
Congress  holds  hearings  on  the  causes  of 
medical  errors  in  the  wake  of  last  year's  Institute 
of  Medicine  report.  Some  congressional 
observers  say  the  ongoing  hearings  will  delve 
into  the  relationship  between  sleep  deprivation 
and  medical  errors. 

Although  the  ACGME  already  had  planned 
the  duty-hour  report,  congressional  inquiries 
and  a request  by  the  AM A Resident  and  Fellow 
Section  last  summer  also  spurred  the  accounting. 

Earlier  this  year.  Dr.  Dunn  collected  duty- 
hour  compliance  information  from  each  of  the 
ACGME's  27  residency  review  committees, 
which  are  charged  with  surveying  the  nation's 
7,731  accredited  graduate  medical  education 
programs. 

"The  number  of  work-hour  citations  has 
increased  every  year  for  surgery  and  several 
other  specialties,"  said  Dr  Dunn,  who  said  the 
causes  may  include  simply  greater  enforcement 
by  the  committees  and  not  necessarily  longer 
hours. 

To  date,  the  ACGME  has  not  withdrawn 
accreditation  of  any  program  solely  for 
overworking  residents.  Even  if  programs  are 
cited  for  violating  one  or  two  ACGME  standards. 
Dr  Dunn  said,  loss  of  accreditation  is  reserved 
for  cases  in  which  multiple  violations  are  found. 
But  accumulation  of  citations  can  lead  to 
probation  or  loss  of  accreditation. 

Christopher  Cogle,  MD,  chair  of  the  AMA's 
resident  section,  said  he  was  encouraged  that  the 
ACGME  was  monitoring  work  hours.  "It  is 
atrocious  so  many  programs  have  been  cited. 
Now  it  is  up  to  the  programs  to  make  changes 
where  residents  work  enough  to  come  into 
contact  with  teaching  cases  but  are  not  pushed 
over  the  curve." 

The  issue  of  resident  work  hours  first  came 
to  public  attention  with  the  accidental  death  of 
Libby  Zion  in  a New  York  City  emergency 
department  more  than  10  years  ago.  Lack  of 
supervision  and  overtired  residents  were 
contributing  factors. 

The  issue  again  came  to  the  forefront  in  1999 
when  a third-year  resident  in  New  York  state 
died  in  a one-car  accident  after  falling  asleep  at 


the  wheel  soon  after  he  completed  an  overnight 
shift. 

One  shortcoming  of  the  ACGME  report  — 
the  lack  of  details  on  types  of  citations  — was 
highlighted  in  a meeting  last  month  of  the 
graduate  medical  education  advisory  committee 
of  the  AMA  Council  on  Medical  Education.  Dr. 
Dunn  said  ACGME  would  provide  more  details 
for  next  year's  report. 

"When  we  looked  at  the  data,  nobody  was 
real  sure  whether  there  are  deficiencies  in 
programs  due  to  lack  of  written  policies  or  [too 
many]  hours  or  days  on  call,"  said  Robert 
Cofield,  MD,  chair  of  the  GME  advisory 
committee.  "We  need  to  better  understand  what 
the  citations  are." 

Charles  Rainey,  MD,  a member  of  the 
resident  section  and  former  chair,  said  programs 
without  written  policies  create  an  environment 
that  can  lead  to  work-hour  abuses. 

But  Dr.  Cofield,  who  also  is  chair  of  the  Dept, 
of  Orthopedic  Surgery  at  Mayo  Clinic  in 
Rochester,  Minn.,  said  most  program  directors 
try  not  to  overwork  residents.  He  added, 
however,  that  some  specialties,  including 
surgery,  require  residents  to  work  long  hours. 

"Surgical  programs  have  a hard  time  with 
the  one-day-off  rule,"  Dr.  Cofield  said.  "Some 
residents  don't  want  to  let  friends  make  rounds 
for  them.  It  might  be  better  for  the  resident  to 
come  in  on  Saturday  and  Sunday  to  check  on 
patients  who  were  operated  on  the  day  before.  I 
suggest  this  is  good  patient  care." 

Although  all  27  specialties  have  require- 
ments for  one  day  off  in  seven,  only  six  residency 
review  committees  have  standards  for  a 
maximum  number  of  hours.  Those  specialties 
are  allergy  and  immunology,  dermatology, 
emergency  medicine,  internal  medicine, 
ophthalmology  and  preventive  medicine.  All 
specialties  are  mandated  by  the  ACGME  to 
prohibit  "excessive"  numbers  of  hours  in 
"patient  care  duties". 

The  American  College  of  Surgeons,  which 
opposes  work-hour  limitations  for  patient 
continuity  of  care  and  because  practicing 
surgeons  are  supposed  to  self-monitor  their 
workload,  has  a long-standing  policy  opposing 


J La  State  Med  Soc  VOL  152  April  2000  157 


work-hour  restrictions. 

In  a 1998  policy  statement,  the  ACS  said: 
"Some  medical  specialties  have  chosen  to  focus 
on  reducing  the  hours  worked  by  residents  as  a 
solution.  ...  Surgeons  have  come  to  a different 
conclusion.  We  have  chosen  to  focus  on  the 
quality  of  the  educational  program." 

Still,  the  ACS  added  this  cautionary  note: 
"The  information  explosion  in  medicine,  the 
increase  in  bureaucracy  that  characterizes 
medical  practice  today,  the  trend  toward 
ambulatory  care  and  a much  abbreviated  hospital 
stay  for  most  patients  ...  have  substantially 
increased  both  the  workload  and  the  stress  of 
surgical  residents." 

But  surgeons  should  be  able  to  work  longer 
hours  than  other  residents,  said  Richard  Reiling, 
MD,  an  ACS  delegate  to  the  AMA  House  of 
Delegates. 

"What  bothers  me  is  that  ...  people  will 
conclude  long  work  hours  lead  to  patient  errors. 
We  don't  know  that,"  said  Dr.  Reiling,  chair  of 
the  surgery  department  at  Kettering  (Ohio) 
Medical  Center.  "Let's  use  evidence-based 
medicine  and  get  the  data  on  whether  there  is  a 
problem.  ...  I don't  think  anybody  can  tell  me 
when  I've  worked  too  much." 

There  are  times  when  Dr.  Reiling  sends 
residents  home.  "If  I send  them  home  too  many 
times,  I have  to  say  this  guy  is  not  cut  out  to  be  a 
surgeon." 

Regardless  of  specialty.  Dr.  Rainey  said, 
residents  should  be  able  to  take  care  of  their 
patients  and  themselves  within  a reasonable 
workweek. 

"We  can't  just  say,  'Our  shift  is  over,  I need  to 
go  home,"'  Dr.  Rainey  said.  "Airline  pilots  and 
truck  drivers  have  hour  limits.  Studies  have 
shown  most  crashes  occur  at  the  end  of  allowable 
hours.  ...  We  need  to  learn  to  be  doctors  in  other 
ways  than  by  fatiguing  ourselves." 

Preliminary  findings  of  a new  survey  on 
resident  work  hours  indicate  residents  are 
working  longer  hours  than  in  the  early  1990s,  said 
DeWitt  Baldwin,  MD,  an  AMA  consultant.  At 
AMNews ' request,  he  reviewed  the  ACGME  duty- 
hour  report. 


"The  specialties  with  the  less  stressful 
residencies  [psychiatry,  medical  genetics  and 
physical  medicine]  are  unlikely  to  have  long 
hours.  That  is  confirmed  in  the  ACGME  survey," 
Dr  Baldwin  said.  "Anesthesiology  and  em- 
ergency medicine,  which  are  demanding  and 
stressful  residencies,  have  taken  steps  to  limit 
hours  and  have  done  a good  job  as  demonstrated 
by  the  survey." 

The  ACGME  cited  2%  of  anesthesiology 
programs  and  10%  of  emergency  medicine 
programs.  But  53%  of  pediatric  surgery  programs 
were  cited. 

"Residents  working  long  hours  in  pediatric 
surgery  makes  sense,"  said  Dr.  Baldwin.  "There 
aren't  many  programs  in  the  country  [13]  and 
few  residents.  That  means  they  are  on  call  all  the 
time.  You  would  think  there  would  be  more 
citations." 

Russell  Chesney,  MD,  chair  of  the  Dept,  of 
Pediatrics  at  LaBonner  Children's  Hospital  in 
Memphis,  said  he  knows  many  program 
directors  who  work  the  same  excessive  hours  as 
residents. 

"Residents  are  off  one  day  in  seven,  and  we 
strive  for  one  night  off  in  four,"  Dr.  Chesney  said. 
"It  is  very  unpopular  with  faculty  because  they 
don't  have  one  day  off  in  seven,  but  we  say  you 
sleep  at  home." 

Residency  programs  cited  in  1999.  (No  citations  were  issued  to 
programs  in  nuclear  medicine,  preventive  medicine,  psychiatry, 
diagnostic  radiology  and  radiation  oncology.) 

RESIDENCY  PROGRAMS 

Reviewed  Cited 

Top  five 


Pediatric  surgery 

13 

7 

(54%) 

General  surgery 

69 

25 

(36%) 

Colon /rectal  surgery 

9 

3 

(33%) 

Internal  medicine 

92 

28 

(30%) 

Orthopedic  surgery 

69 

20 

(29%) 

Bottom  five 

Urology 

49 

4 

( 8%) 

Dermatology 
Anatomic  / pathology 

29 

2 

( 7%) 

clinical  subspec. 

107 

6 

( 6%) 

Medical  genetics 

17 

1 

( 6%) 

Anesthesiology 

135 

2 

( 1%) 

Source:  Accreditation  Council  for  Graduate  Medical  Education 


158  J La  State  Med  Soc  VOL  152  April  2000 




I 


Planning  for 
Influenza  Season  2000 

Provided  by  the  Louisiana  Health  Care  Review 


Louisiana's  influenza  immunization  rate  for  Medicare  beneficiaries  is  among  the  lowest  in  the 
UnitedStates  Louisiana  Health  Care  Review  recommends  beginning  preparations  early  for 
the  2000  influenza  season  and  makes  the  following  suggestions  for  setting  up  an  influenza 
immunization  clinic. 


•Pre-order  vaccine 

April 

•Order  patient  education  materials 

July/  August 

•Order  physician  chart  reminders 

July/  August 

•Train  staff  on  billing  for  immunizations 

July/  August 

•Provide  ACIP  guidelines  and  algorithms  to  physicians 

July  / August 

•Prepare  referral  system 

July  / August 

•Mail  out  patient  reminders 

August /September 

•Medical  record  documentation 

September-December 

•Schedule  and  staff  immunization  clinic 

September-December 

For  a list  of  vaccine  suppliers,  more  detailed  information  about  setting  up  an  influenza  clinic,  parish 
immunization  rates  for  Medicare  beneficiaries,  and  links  to  related  websites,  please  visit  LHCR  at 
www.lhcr.org.  You  may  also  contact  Jack  Olden,  RN,  MA,  Outpatient  Co-Director  at  (225)926-6353  or 
lapro.jolden@sdps.org. 


J La  State  Med  Soc  VOL  152  April  2000  159 


ONE  CHOICE. 


When  someone  you  care  about  is  diagnosed 
with  cancer,  you  want  the  best. 

Make  Mary  Bird  Perkins  Cancer  Center  your 
first  choice  for  treatment. 


Hammond 


Covington 

★ 


Working  together  with  the  expert 
physicians  in  your  community,  we  make 
your  care  our  first  priority. 

For  nearly  30  years,  cancer  has  been  our 
one  and  only  focus.  Keeping  current  with 
state-of-the-art  equipment  and  technology 
and  clinical  research,  will  help  you  and 
your  doctor  choose  the  best  care. 


Mary  Bird  Perkins 

CANCER  CENTER 
Your  First  Choice ” in  Cancer  Care. 


4950  Essen  Lane  ■ Baton  Rouge,  Louisiana  ■ 70809-3482  -(800)489-7800 
15728  Medical  Center  Drive  • Hammond,  Louisiana  ■ 70403-6703  • (800)467-7600 
1006  South  Harrison  Street  ■ Covington,  Louisiana  • 70433-3611  ■ (877)467-8600 

www.marybird.org 


Cancer  in  Louisiana 


The  Louisiana  Cancer  and 
Lung  Trust  Fund  Board 

Ray  S.  Whiting  and  Donna  Williams,  MS,  MPH 


The  Louisiana  Cancer  and  Lung  Trust  Fund  Board,  begun  in  1980,  continues  to  move 
forward  in  its  mission  in  cancer  research  and  tobacco  control.  During  the  last  year,  the 
Board  has  created  a presence  on  the  World  Wide  Web,  and  taken  steps  to  implement 
the  Cancer  Control  Strategic  Plan.  Several  new  representatives  have  been  appointed 
to  the  Board,  replacing  retiring  members.  The  Board  continues  its  leading  role  in  the 
development  of  the  Tobacco  Control  Coalition.  Listed  at  the  end  of  this  article  is  a 
summary  of  the  Board's  legislative  mandate,  its  membership,  and  its  current  officers. 


The  Louisiana  Cancer  and  Lung  Trust 
Fund  Board  has  organized  and 
sponsored  the  April  issue  of  the 
JOURNAL  since  1984,  devoting  the  issue  to 
cancer  and  the  cancer  problem  in  Louisiana. 
Included  in  this  issue  are  articles  produced  as  a 
result  of  grants  funded  by  the  Louisiana  Cancer 
and  Lung  Trust  Fund  Board. 

RESEARCH  FUNDING  - LOUISIANA’S 
RETURN  ON  INVESTMENT? 

The  Louisiana  Cancer  and  Lung  Trust  Fund 
Board  has  the  responsibility  of  distributing  funds 
for  cancer  research  within  Louisiana.  The 
Board's  research  program  provides  1-year 


funding  for  investigators  to  work  on  various 
cancer-related  projects.  This  year,  grant 
applications  were  solicited  for  research  in  one 
of  these  categories: 

1.  Evaluation  of  Cancer  Problems  Unique  to 
Louisiana  - access  to  health  care,  lifestyles 
(including  knowledge /attitudes/  practice), 
and  other  issues  having  impact  on  cancer  and 
cancer-related  problems  unique  to  Louisiana. 

2.  Relationship  of  Tobacco  Use /Smoking  to 
Pulmonary,  Cardiovascular,  and  Malignant 
Diseases  - this  category  invited  research  pro- 
posals that  will  explore  the  relationship  of 
tobacco  use/ smoking  to  various  pulmonary, 
cardiovascular,  and  malignant  diseases. 

3.  Prevention  Research  in  regard  to  Cancer/ 


J La  State  Med  Soc  VOL  152  April  2000  161 


Cancer  in  Louisiana 


Pulmonary  Disease  - proposals  responding  to 
this  category  examine  human  behaviors,  at- 
titudes, and  beliefs  that  contribute  toward 
prevention  of  cancer /pulmonary  disease. 

4.  Cancer  Prevention  and  Control  focused  on 
Smoking /Tobacco-related  illness  - research 
projects  under  this  category  are  more  spe- 
cific than  the  previous  and  focus  on  strate- 
gies to  control/ prevent  smoking-related  can- 
cers by  controlling  and  / or  preventing  smok- 
ing/tobacco use. 

The  first  priority  of  research  is,  without  question, 
finding  answers  to  the  health  problems  facing 
Louisiana.  A second  issue,  however,  arises  when 
grants  are  used  as  "seed  money"  to  begin 
projects  that  progress  far  enough  to  attract 
additional  funding  from  external  sources.  Since 
starting  the  program  in  1984,  until  the  1999  grant 
cycle,  the  Board  has  received  grant  applications 
representing  $7,696,501  in  requested  funding 
(Figure  1).  Of  that,  LCLTFB  has  only  awarded 
$2,283,368  in  research  grants,  plus  $145,014 
toward  Tumor  Registry  enhancements 
($2,428,382  in  total  awards)  . 

In  the  Spring  of  1999,  the  Board  polled  the 
grants  administration  offices  of  the  primary 
grant  recipient  institutions  to  determine  what 
external  funding  has  been  received  as  a direct 
result  of  projects  originally  funded  by  the  Board. 
These  institutions  were  LSU  Flealth  Sciences 
Center  in  New  Orleans,  Tulane  University 
Medical  Center,  and  LSU  Health  Sciences  Center 
in  Shreveport.  Records  were  only  available  back 
to  1990. 

During  the  period  1990-1998,  the  Board 
received  grant  applications  requesting 
$3,603,584,  and  was  only  able  to  fund  $1,444,377. 
Of  this  funding,  $1,020,775  resulted  in 
investigators  being  able  to  receive  $4,275,014  in 
additional  funding  from  external  sources  (Figure 
2)  directly  attributable  to  projects  originally 
funded  by  the  Board.  Of  total  funding  for  that 
period  (1990-1999),  there  was  nearly  a three-fold 
return  (296%)  on  the  state  money  invested  in 
cancer  research.  If  the  Board  had  been  funded 
sufficiently  by  the  state  and  thus  able  to  award 


all  grant  applicants  ($7,696,501),  our  state  cancer 
researchers  could  have  potentially  had  nearly 
three  times  that  amount:  $22,781,624. 

Even  if  we  assume  that  the  $4,275,014 
reflected  total  external  funding  resulting  from 
total  Board  funding  for  the  entire  period  1984- 
1999,  instead  of  just  during  the  last  nine  years,  it 
is  still  roughly  187%  return  — almost  double,  or 
$14,392,456  in  additional  external  funding. 

In  some  years  there  were  projects  that  did 
not  adequately  pass  peer-review  to  warrant 
funding;  however,  the  Board  has  never  lacked 
suitable  and  fundable  project  proposals.  The 
problem  is  that  available  funding  has 
consistently  been  inadequate,  and  the  Board  has 
consistently  had  to  deny  funding  to  worthy 
projects.  The  Louisiana  Cancer  and  Lung  Trust 
Fund  Board  has  had  the  same  annual  budget  for 
at  least  the  last  7 years  (during  which  time  this 
author  has  been  administrator),  and  quite  likely 
the  same  budget  for  many  years  prior  to  1990. 

It  is  evident  that  our  state's  researchers 
continue  to  produce  sound  research  proposals; 
it  is  evident  these  proposals  can  be  developed 
and  many  in  fact  do  attract  federal  and  other 
dollars  into  this  state.  What  is  not  evident  is  why, 
in  light  of  this  potential  for  securing  greater 
funding  for  the  state  of  Louisiana,  the  Board 
appointed  by  the  Governor  for  this  purpose  is 
constrained  to  addressing  cancer  issues  in  the 
year  2000  with  a budget  virtually  unchanged 
since  1990. 

CANCER  CONTROL  PLAN 

Donna  Williams  has  been  working  at  fifty 
percent  effort  for  the  Board  since  January  of  1999. 
Since  then,  she  has  been  working  toward 
implementation  of  the  Cancer  Control  Plan.  She 
has  been  determining  the  existing  prevention 
and  early  detection  programs  around  the  state 
for  breast,  cervical,  colorectal,  and  prostate 
cancers.  This  has  included  gathering  information 
from  the  public  hospitals,  American  College  of 
Surgeons  accredited  sites,  and  state-run  clinics. 
She  has  also  been  working  with  the  state  hospital 


162  J La  State  Med  Soc  VOL  152  April  2000 


Cancer  in  Louisiana 


system,  implementing  and  fine  timing  the  cancer 
screening  program  at  four  sites.  Keys  to  the 
statewide  implementation  of  any  plan  are 
partnerships  and  collaborations.  Successful 
cancer  screening  programs  will  be  based  on 
assisting  and  encouraging  primary  care 
physicians  in  offering  screening  tests  to  their 
patients  as  well  as  educating  the  public  as  to  the 
importance  of  these  tests.  Ms  Williams  is 
cultivating  the  kinds  of  partnerships  that  will 
foster  successful  programs,  such  as  working 
with  the  Louisiana  Health  Care  Review  to  reach 
physicians  and  the  Cooperative  Extension 
Sendees  to  reach  appropriate  participants. 

During  this  next  year,  Ms  Williams  hopes  to 
further  collaborations,  implement  pilot  pro- 
grams, and  be  a resource  to  primary  care 
physicians  on  appropriate  cancer  control 
measures.  Physicians  and  organizations  around 
the  state  are  encouraged  to  work  with  Ms 
Williams  in  this  important  undertaking. 

COALITION  FOR  A 
TOBACCO-FREE  LOUISIANA 

The  Louisiana  Cancer  and  Lung  Trust  Fund 
Board  has  taken  a leading  role  in  estabhshing 
the  Coalition  for  a Tobacco-free  Louisiana.  This 
organization  was  very  active  during  the  last 
legislative  session  in  trying  to  obtain  significant 
money  from  the  Master  Settlement  Agreement 
with  the  tobacco  companies  for  tobacco 
prevention  and  cessation.  Unfortunately,  only  $3 
million  was  in  the  budget  of  the  Office  of  Public 
Health  for  a statewide  effort.  This  money  has 
yet  to  be  approved  for  spending.  The  future 
money  from  the  Master  Settlement  Agreement 
will  be  spent  as  dictated  by  the  Constitutional 
Amendment  recently  passed. 

The  Coalition  will  continue  its  anti-tobacco 
efforts  under  the  guidance  of  the  Louisiana 
Public  Health  Institute.  Tobacco  use  statistics, 
particularly  in  adolescents,  continue  to  worsen. 
The  need  grows;  the  resources  become  less. 
Therefore  an  ongoing  effort  by  all  interested 
parties  must  continue. 


Tobacco  use  is  the  leading  cause  of  death  in 
Louisiana.  One  of  these  days,  it  will  receive  the 
attention  it  deserves  because  of  its  effect  on  our 
health  and  economy.  The  Coalition  will  continue 
trying  to  make  this  happen. 

GRANTS  AWARDED  FOR  1999-2000 

The  research  projects  currently  funded  by  the 
Louisiana  Cancer  and  Lung  Trust  Fund  Board 
for  fiscal  year  1999-2000  are: 

♦ An  Experimental  Model  of  Gastric 
Carcinogenesis,  Infection  of  Mongolian  Gerbils 
with  Helicobacter  Pylori.  (Bernardo  Ruiz,  MD, 
PhD,  LSU  Health  Sciences  Center,  New  Orleans) 
This  research  project  was  awarded  the  Rebecca 
Davilene  Carter  Grant  for  Research  in  Cancer, 
1999-2000. 

♦ Resiliency  in  Youth:  What  Influences  Them 
Not  To  Smoke?  (Connie  Arnold,  PhD,  LSU 
Health  Science  Center,  Shreveport). 

♦ From  Experimenter  to  Addiction: 
Understanding  the  Early  Natural  History  of 
Tobacco  Use.  (Saundra  MacD  Hunter,  PhD,  LSU 
Health  Sciences  Center,  New  Orleans). 

ABOUT  THE  LOUISIANA  CANCER  AND 
LUNG  TRUST  FUND  BOARD 

The  Louisiana  Cancer  and  Lung  Trust  Fund 
Board  was  established  in  1980,  composed  of  12 
institutions  and  agencies  throughout  the  state. 
It  was  given  the  following  two-fold  legislative 
mandate: 

B.  The  board  shall  determine  the  eligibility 
of  medical  research  programs  and  clinical 
investigation  and  training  projects  to  receive 
funds;  however,  sufficient  funds  shall  be 
allocated  annually  to  the  statewide  registry 
program  for  reporting  cancer  cases  under 


J La  State  Med  Soc  VOL  152  April  2000  163 


Cancer  in  Louisiana 


the  provisions  ofR.S.  40:1299.80  et  seq. 

* * * 

C.(l)  The  board  shall  establish  rules  and 
regulations  for  its  own  procedures,  establish 
policies  for  the  operation  of  a statewide 
registry  program  for  reporting  cancer  cases 
established  under  the  provisions  of  R.S. 
40:1299.80  et  seq.,  establish  criteria  for 
review  panels,  and  establish  guidelines  and 
deadlines  for  grant  applications  to  be 
submitted. 

(Louisiana  Revised  Statutes  40:1299.88) 

Current  representation  on  the  Board  is  as 

follows: 

♦ Hans  J.  Berkel,  MD,  PhD,  LSU  Medical 
Center  - Shreveport 

♦ Charles  L.  Brown  Jr,  MD,  American  Cancer 
Society 

♦ Carl  G.  Kardinal,  MD,  Leukemia  Society  of 
America,  Louisiana  division 

♦ Carol  M.  Mason,  MD,  American  Lung 
Association 

♦ William  M.  Pinsky,  MD,  Ochsner  Medical 
Foundation 

♦ John  M.  Rainey,  MD,  Acadiana  Medical 
Research  Foundation 

♦ Lehrue  Stevens,  MD,  Louisiana  State  Medical 
Society 

♦ Todd  D.  Stevens,  MBA,  Mary  Bird  Perkins 
Foundation 

♦ Oliver  Sartor,  MD,  LSU  Medical  Center  - 
New  Orleans 

♦ Jack  P.  Strong,  MD  , American  Heart 
Association 

♦ Robert  L.  Thomas,  PhD,  Xavier  University 
School  of  Pharmacy 

♦ Roy  S.  Weiner,  MD,  Tulane  Medical  School 

Staff  in  support  of  the  Board: 

Donna  Williams,  MS,  MPH,  LCLTFB  Cancer 

Control  Officer 

Ray  S.  Whiting,  LCLTFB  Administrator 


THE  MISSION  OF  THE  LOUISIANA  CANCER 
AND  LUNG  TRUST  FUND  BOARD 

The  mission  of  the  Louisiana  Cancer  and  Lung 
Trust  Fund  Board  is  to  promote  activities  that 
target  cancer  control  and  cardio-pulmonary 
diseases  in  the  State  of  Louisiana.  Such  activities 
include,  but  are  not  limited  to,  the  prevention  of 
cancer  and  the  treatment  and  rehabilitation  of 
cancer  patients.  Accurate  identification  and 
characterization  of  the  magnitude  of  the  cancer 
burden  for  the  residents  of  Louisiana  and  the 
identification  of  high-risk  groups  will  be  a major 
concern  of  the  Board.  Activities  will  be 
undertaken  to  reduce  cancer  incidence  and 
mortality  rates  as  well  as  to  improve  the  survival, 
and  the  quality  of  life  of  cancer  patients  and 
cancer  survivors.  The  Board  will  foster  research 
on  the  epidemiology,  causation,  prevention,  and 
medical  care  aspects  of  cancer.  Educational 
activities  directed  to  patients,  health  care 
providers,  and  the  public  in  general  will  be 
promoted  by  the  Board.  The  Board  will  work 
together  with  governmental,  academic, 
philanthropic,  and  private  institutions  to 
promote  its  activities. 


Mr  Whiting  is  the  Administrator  of  the 
Louisiana  Cancer  and  Lung  Trust  Fund  Board. 

Ms  Williams  is  the  Cancer  Control  Officer 
of  the  Louisiana  Cancer  and  Lung 
Trust  Fund  Board. 


164  J La  State  Med  Soc  VOL  152  April  2000 


Cancer  in  Louisiana 


A Guide  to  Act  199: 

The  Treatment  of  Breast  Cancer 

Donna  L.  Williams,  MS,  MPH  and  Charles  L.  Brown  Jr,  MD 


Act  199  of  the  Louisiana  1999  Regular  Legislative  Session  requires  "physicians  and  surgeons 
to  discuss  and  provide  to  their  patients  diagnosed  with  breast  cancer  a written  summary  of 
treatment  alternatives."  Many  other  states  have  similar  laws  requiring  written  summaries. 
This  summary  should  serve  as  a guide  to  discussions  with  patients.  Even  though  this  type  of 
legislation  is  controversial,  it  is  important  that  physicians  take  the  lead  in  developing  accurate 
and  helpful  information  for  their  patients. 


The  Louisiana  1999  Regular  Legislative  Session 
saw  over  500  bills  related  to  health  care  intro- 
duced with  184  passed  and  signed  into  law. 
Among  these  was  a bill  that  was  passed  unani- 
mously and  with  little  debate.  It  is  now  written 
into  history  as  Act  199.  Act  199  requires  "physi- 
cians and  surgeons  to  discuss  and  provide  a 
written  summary  of  treatment  alternatives  to 
their  patients  diagnosed  with  breast  cancer." 

Reactions  to  this  law  have  ranged  from  the 
enthusiastic  "it's  about  time"  to  the  disgruntled 
"that's  meddlesome".  Some  find  it  disturbing 
that  legislators  are  dictating  the  doctor  / patient 
relationship.  However,  it  should  be  noted  that 
the  bill  was  sponsored  by  two  senators  and  four 
representatives,  all  women  and  all  potential 
patients.  This  is  obviously  an  important  issue 


to  women  in  the  state.  Senator  Bajoie,  one  of  the 
bill's  sponsors,  indicated  that  in  past  years  she 
has  had  constituents  express  concerns  regard- 
ing physicians  not  having  time  to  educate  pa- 
tients regarding  their  options.  She  also  pointed 
out  that  women  may  make  different  decisions 
at  different  times  in  their  lives,  further  highlight- 
ing the  urgency  of  education  about  the  various 
types  of  therapy.  Her  hope  with  this  bill  was  to 
encourage  the  kinds  of  discussions  between 
doctors  and  patients  that  would  make  the  diffi- 
cult decisions  regarding  their  breast  cancer  treat- 
ment easier  to  understand. 

This  kind  of  bill  is  not  new.  As  of  August, 
1998,  eleven  other  states  had  breast  cancer  treat- 
ment alternative  laws.1  California,  the  model  for 
the  Louisiana  act,  was  the  first  to  enact  such  a 


J La  State  Med  Soc  VOL  152  April  2000  165 


Cancer  in  Louisiana 


law  as  far  back  as  1980. 

The  requirements  of  these  laws  differ  widely. 
Texas,  at  one  end  of  the  spectrum,  allows  for  in- 
formation to  be  distributed  when  the  physician's 
professional  judgment  determines  it  is  in  the 
patient's  best  interest.  Louisiana,  California, 
Kentucky,  Maine,  Maryland,  Minnesota,  Mon- 
tana, and  New  York  require  the  information  to 
be  given  to  any  patient  diagnosed  with  breast 
cancer.  Montana  requires  the  patient  to  sign  a 
written  consent  indicating  that  she  has  received 
such  information.  Florida  and  Kansas  take  it  a 
step  further:  Florida  requires  informing  anyone 
at  high  risk  of  being  diagnosed  with  breast  can- 
cer; Kansas  includes  any  patient  suffering  from 
any  form  of  abnormality  of  the  breast  tissue  for 
which  surgery  is  recommended. 

Louisiana,  as  in  eight  other  states,  requires 
the  adoption  of  a standard  written  summary. 
California  and  Florida,  for  example,  developed 
their  own  summaries,  which  are  29  and  32  pages 
respectively.  Kentucky,  on  the  other  hand, 
adopted  the  NCI  publication.  Understanding 
Breast  Cancer  Treatment:  A Guide  for  Patients.  The 
Louisiana  law  requires  that  our  summary  in- 
clude: 

(1)  Information  regarding  any  method  of  treat- 
ment for  breast  cancer  that  is  in  the  investi- 
gational or  clinical  trial  stage  and  is  recog- 
nized for  treatment  by  the  Physician's  Data 
Query  of  the  National  Cancer  Institute; 

(2)  Available  telephone  numbers,  including  but 
not  limited  to,  toll-free  numbers  for  the  Na- 
tional Cancer  Institute  and  the  American 
Cancer  Society,  to  allow  a breast  cancer  pa- 
tient to  obtain  current  breast  cancer  informa- 
tion; 

(3)  A discussion  of  breast  cancer  reconstructive 
surgery,  including  but  not  limited  to  prob- 
lems, benefits,  and  alternatives;  and 

(4)  Statistics  on  the  incidence  of  breast  cancer. 

The  challenge  of  creating  Louisiana's  sum- 
mary was  given  to  the  Department  of  Health  and 
Hospitals  and  the  Louisiana  Cancer  and  Lung 
Trust  Fund  Board.  The  intent  of  DHH  and 


LCLTFB  was  to  create  a written  product  that 
would  be  easily  managed  at  the  physician's  level 
while  still  containing  the  pertinent  information. 
The  NCI  booklet,  for  example,  is  well  written 
and  covers  all  the  points,  but  would  require 
physicians  to  order  and  store  a supply.  There- 
fore, a one-page  pamphlet  was  developed  for 
your  patients.  This  should  serve  as  a guide  to 
doctor /patient  dialog.  The  text  of  this  pamphlet 
is  reproduced  below: 

WHAT  YOU  SHOULD  KNOW  ABOUT  THE 
TREATMENT  OF  BREAST  CANCER 

WHAT  IS  BREAST  CANCER? 

Breast  Cancer  occurs  when  cells  in  the  breast  become 
abnormal  and  divide  in  an  out-of-control  manner. 

YOU  SHOULD  KNOW: 

■ft  That  there  is  no  one  right  treatment  for  all  women. 
Find  out  your  options; 

You  can  ask  questions  and  write  down  or  record 
your  doctor’s  answers; 

A You  do  not  have  to  decide  overnight.  You  should 
start  treatment  within  a couple  of  weeks  of  diagno- 
sis; 

fV  Why  any  test  or  procedure  is  being  done  and  what 
the  risks  are; 

■ft  You  can  ask  another  doctor  about  your  treatment 
choices  (“second  opinion”). 

TREATING  RREAST  CANCER 

There  are  four  main  ways  to  treat  breast  cancer:  surgery, 
radiation  therapy,  chemotherapy,  and  hormone  therapy 
or  any  combination  of  these.  The  best  for  you  will 
depend  on: 

size  of  your  tumor  (lump); 
if  the  cancer  has  spread  (stage); 


166  J La  State  Med  Soc  VOL  152  April  2000 


Cancer  in  Louisiana 


ft  how  your  tumor  reacts  to  certain  hormones; 
ft  the  type  of  genetic  material  in  the  cancer  cells; 
ft  the  rate  the  cells  are  growing; 
ft  your  age  and  general  health. 

Surgery 

There  are  two  types  of  surgery  for  breast  cancer: 
breast-conserving  - only  part  of  the  breast  is 
removed;  and  mastectomy  - removing  the  entire 
breast. 

1.  Breast-Conserving  Surgery 

Lumpectomy  - surgery  that  removes  the  tumor  and 
some  of  the  tissue  around  it. 

Partial  or  Segmental  Mastectomy  - the  tumor,  some 
tissue  around  it,  and  the  lining  over  the  chest  muscle 
is  removed. 

If  you  have  breast-conserving  surgery,  you  will 
also  have  radiation  therapy  to  destroy  any  remaining 
cancer  cells. 

ft  For  early  breast  cancer,  breast-conserving  surgery 
with  radiation  is  as  effective  as  mastectomy. 
ft  You  may  have  a change  in  breast  shape,  espe- 
cially if  the  tumor  was  large. 

2.  Mastectomy  - the  removal  of  the  breast.  This 
may  be  your  best  option  if  you  have  more  than  one 

tumor  or  a large  tumor.  The  several  types  of 
mastectomies  vary  in  how  much  tissue  is  removed. 
ft  If  the  tumor  is  large  or  there  are  several  abnormal 
areas  in  the  breast,  a mastectomy  and  reconstruc- 
tion may  have  better  cosmetic  results  than  a 
lumpectomy. 

ft  Ask  about  surgery  to  rebuild  the  breast. 


Lymphadenectomy  is  the  removal  of  lymph  nodes  in 
the  armpit  to  which  the  cancer  may  have  spread.  With 
mastectomy,  the  lymph  nodes  are  removed  at  the 
same  time.  With  breast-conserving  surgery,  lymph 
nodes  may  be  removed  in  another  operation. 

Radiation  Therapy 

Radiation  therapy  is  used  in  addition  to  surgery.  It  uses 
high-energy  rays  to  kill  cancer  cells  that  may  be  in  the 
breast  and  lymph  nodes  after  surgery.  Radiation  therapy 
is  generally  considered  necessary  after  breast- 
conserving  surgery,  but  may  also  be  necessary  after 
mastectomy. 

ft  With  radiation,  breast-conserving  surgery  for  early 
breast  cancer  is  as  effective  as  mastectomy; 
ft  Radiation  therapy  can  involve  daily  visits  for  six 
weeks; 

ft  Radiation  to  the  breast  does  not  cause  hair  loss, 
vomiting,  or  diarrhea,  but  has  local  side  effects  you 
should  ask  about. 

Chemotherapy 

Chemotherapy  means  “treatment  with  drugs.”  Many 
drugs  are  used  for  breast  cancer.  Your  doctor  will 
suggest  the  drugs  most  effective  for  your  cancer  type. 
ft  With  surgery  and  radiation,  chemotherapy  may 
make  treatment  more  successful; 
ft  Side  effects  depend  on  the  drugs,  but  can  include 
loss  of  appetite,  nausea,  vomiting,  diarrhea,  hair 
loss,  mouth  sores,  constipation,  weight  change,  lack 
of  energy,  increased  chance  of  infection,  and  sore 
throat.  There  are  treatments  that  can  help  reduce 
most  of  these  side  effects. 


J La  State  Med  Soc  VOL  152  April  2000  167 


Cancer  in  Louisiana 


Hormone  Therapy 

Hormones  are  chemicals  your  body  makes  to  control 
many  functions.  If  hormones  make  your  tumor  grow, 
your  doctor  may  suggest  therapy  that  blocks  hormones 
from  getting  to  cancer  cells. 

A May  need  to  take  pills  for  five  years; 

A May  increase  uterine  cancer  risk. 

Breast  Reconstruction 

If  you  have  a mastectomy,  your  breast  may  be  able  to 
be  reconstructed  or  rebuilt  at  the  time  that  your 
mastectomy  is  done  or  at  a later  date.  Ask  your  doctor 
about  your  options  before  you  start  treatment.  There 
are  several  ways  to  rebuild  a breast: 

A From  skin,  muscle,  and  fat  from  another  part  of  your 
body; 

A Using  a breast  implant.  A breast  implant  is  a sac 
placed  under  the  skin  or  chest  muscle. 

Things  to  Consider  About  Breast  Reconstruction : 

A In  clothes,  you  will  look  like  you  did  before  sur- 
gery; 

A You  may  need  more  than  one  surgery  to  complete 
the  reconstruction; 

A A reconstructed  breast  may  not  have  natural  feel- 
ings and  will  not  look  exactly  like  your  removed 
breast; 

A Each  option  for  breast  reconstruction  needs  to  be 
fully  explained  to  you  by  the  doctor  doing  the  sur- 
gery; 

A Ask  about  the  effects  on  “self-exam”  and  mammog- 
raphy; 

A Ask  about  timing  with  respect  to  radiation  therapy. 


Clinical  Trials 

New  and  improved  drugs  to  treat  people  have  to  be 
tested  in  people.  These  tests,  called  clinical  trials,  help 
doctors: 

A Learn  if  a drug  works  and  is  safe; 

A Know  what  dose  works  best; 

A Know  what  side  effects  it  may  cause,  if  any. 

Many  clinical  trials  are  designed  for  outpatients,  and 
let  participants  go  about  their  normal  activities.  Clinical 
trials  tend  to  require  about  the  same  time  and  number 
of  doctor  visits  as  standard  therapy,  but  you  might  have 
to  give  blood  samples  or  take  tests  more  often  to  monitor 
your  response.  The  clinical  trial  must  be  explained  to 
you  fully  and  you  must  agree  to  the  conditions.  The 
hope  of  benefiting  from  a new  drug  or  the  desire  to 
take  part  in  research  that  might  benefit  others  helps 
people  volunteer  for  clinical  trials.  If  interested,  discuss 
this  with  your  doctor  or  contact: 

National  Cancer  Institute 
Cancer  Information  Service 
1 -800-4-CANCER 
Deaf  callers:  1-800-332-8615 
cancertrials.  nci.nih.gov 

Centerwatch  Clinical  Trials  Listing  Service 
(617)  856-5900 
www.  centerwatch.  com 

BREAST  CANCER  STATISTICS 
A It  is  the  most  common  cancer  in  women  in 
the  U.S.  and  Louisiana.  About  1/3  of  all 
cancer  cases  in  women  are  breast  cancer; 

A One  out  of  eight  American  women  will  get 
breast  cancer. 


168  J La  State  Med  Soc  VOL  152  April  2000 


Cancer  in  Louisiana 


In  Louisiana... 

A Women  have  a lower  risk  of  breast  cancer 


than  women  in  the  United  States. 


White 

African  American 

Louisiana 

99  per  100,000 

87  per  100,000 

US 

115  per  100,000 

101  per  100,000 

For  more  details  on  this  information,  you  can: 

Call  Toll  Free  877-4-LCLTFB  (877-452-5832);  or 
Download  or  read  at  http://rex.nci.nih.gov/PATIENTS/ 
aboutbc/ ubc_treatmen  t.h  tml. 

-End  of  Pamphlet - 


A Deaths  rates  are  either  higher  or  similar  to 


the  national  average. 


White 

African  American 

Louisiana 

24  per  100,000 

33  per  100,000 

US 

26  per  100,000 

32  per  100,000 

Five-year  Relative  Survival  Rates  by  Stage  at 
Diagnosis 


Breast  Cancer 

Percent  Surviving 

All  Stages 

84 

Local 

97 

Regional 

16 

Distant 

20 

American  Cancer  Society  Facts  and  Figures 

PLACES  TO  FIND  MORE  INFORMATION 

National  Cancer  Institute  Cancer  Information  Service 
1 -800-4-CANCER 
rex.nci.nih.gov 

American  Cancer  Society  National 
1-800-ACS-2345 
www.  cancer,  org 

Amercian  Cancer  Society  Louisiana 
(504)  469-0021 

www  2.  cancer,  org/state/la/index.  html 
Susan  G.  Komen  Foundation 
1-800-462-9273 
www. komen.org 


This  pamphlet  can  be  obtained  by  contacting  the 
Louisiana  State  Board  of  Medical  Examiners  or 
from  the  Louisiana  Cancer  and  Lung  Trust  Fund 
Board  website  at  www.lcltfb.org.  Making  the  pam- 
phlet available  on  the  internet  should  meet  the 
goal  of  making  the  required  summary  easily  ac- 
cessible and  manageable.  It  can  even  be  saved 
as  a file  on  an  office  computer. 

Act  199  also  requires  that  the  Louisiana  State 
Board  of  Medical  Examiners  distribute  this  sum- 
mary to  all  physicians  licensed  in  Louisiana.  The 
Board  will  do  so  in  its  Spring  2000  newsletter. 
Furthermore,  the  board  will  provide  a copy  of 
the  brochure  to  physicians  upon  renewal  of  their 
licenses  in  the  year  2001.  In  subsequent  years, 
all  new  licensees  will  receive  a copy  of  the  bro- 
chure with  their  licenses. 

It  is  important  that  physicians  take  the  lead 
in  developing  accurate  and  helpful  information 
for  patients.  This  pamphlet  was  designed  to  cre- 
ate an  environment  for  open  and  informed  dis- 
cussion about  breast  cancer. 


Ms  Williams  is  the  Cancer  Control  Officer  at  the  Louisi- 
ana Cancer  and  Lung  Trust  Fund  Board. 

Dr  Brown  is  a professor  of  the 
Department  of  Public  Health  and  Preventative  Medicine  at 
Louisiana  State  University  Health  Sciences  Center  and 
a member  of  the  Louisiana  Cancer  and  Lung 

Trust  Fund  Board. 


J La  State  Med  Soc  VOL  152  April  2000  169 


The  Journal  of  the  Louisiana  State  Medical  Society 
invites  members  to  submit  any  of  the 
following  items  for  publication: 

* Scientific  Studies 

* Letters  to  the  Editor 

✓ Viewpoints 

* Socioeconomic  Papers 
«/  Medicolegal  Papers 

✓ Societal  Reports 

For  more  information,  contact 
Editor  Conway  Magee,  MD  (337)  439-8450 
or  Managing  Editor  Anne  Shirley  (225)  763-8500 

For  manuscript  specifications, 
see  page  136,  "Information  for  Authors". 


Cancer  in  Louisiana 


Stage  of  Disease  at  Diagnosis  and 
Survival  Estimates  for  Cancers  of  the  Colon 

and  Rectum  in  Louisiana 

Xiao  Cheng  Wu,  MD,  MPH,  CTR;  Catherine  N.  Correa,  MPH,  PhD;  Patricia  A. 
Andrews,  MPH,  CTR;  Beth  A.  Schmidt,  MSPH;  Mohammed  N.  Ahmed,  MD,  MPH; 
Vivien  W.  Chen,  PhD;  and  Elizabeth  T.H.  Fontham,  DrPH 


Survival  from  cancers  of  the  colon  and  rec- 
tum, collectively  referred  to  as  colorectal 
cancers,  can  be  greatly  increased  if  tu- 
mors are  detected  early  and  if  appropriate  treat- 
ment is  provided.  Screening  for  colorectal  can- 
cer has  been  reported  to  reduce  both  incidence 
and  mortality.1'9  Nearly  all  colorectal  cancers 
develop  from  precancerous  polyps.1011  The  ra- 
tionale behind  screening  tests  for  colorectal  can- 
cer is  to  detect  and  remove  precancerous  pol- 
yps before  they  become  cancerous.  The  transi- 
tion from  benign  polyps  to  colorectal  cancer  is 
a slow  process,  taking  an  estimated  10-15 
years,12  and  patients  are  asymptomatic  in  the 
early  part  of  this  process.  If  precancerous  pol- 
yps can  be  detected  and  removed  during  this 
period,  cancers  can  be  prevented.  Even  if  pol- 


yps have  progressed  to  malignancy  at  the  time 
of  detection,  patients  diagnosed  with  early  stage 
disease  have  better  prognosis  than  those  diag- 
nosed at  a more  advanced  stage.  Ninety  percent 
of  patients  with  localized  disease  survive  at  least 
5 years  after  diagnosis  with  colorectal  cancer. 
However,  the  5-year  survival  rate  decreases  to 
65%  for  patients  with  regional  spread  and  to  8% 
among  those  with  distant  metastases.13 

Several  major  groups  have  provided  recom- 
mendations on  types  of  screening  tests  for 
colorectal  cancer  and  the  optimal  intervals  be- 
tween screenings.14'16  The  screening  tools  include 
digital  rectal  examination  (DRE),  fecal  occult 
blood  test  (FOBT),  flexible  sigmoidoscopy, 
colonoscopy,  and  double  contrast  barium  enema 
(DCBE).  Colonoscopy  and  DCBE  generally  have 


J La  State  Med  Soc  VOL  152  April  2000  171 


Cancer  in  Louisiana 


been  recommended  for  screening  individuals  at 
higher  risk  for  colorectal  cancer  and  for  follow- 
up testing  of  those  who  have  had  abnormalities 
detected  on  the  other  screening  tests.  About  75% 
of  all  new  cases  of  colorectal  cancer  occur  in 
people  who  have  no  known  predisposing  fac- 
tors and  are  therefore  considered  to  be  at  aver- 
age risk.12  The  rest  are  considered  at  increased 
or  above-average  risk  because  of  inherited  or 
acquired  susceptibility  such  as  inflammatory 
bowel  disease,  familial  adenomatous  polyposis, 
or  hereditary  nonpolyposis  colorectal  cancer. 

Previous  studies  show  that  the  1990-1994  in- 
cidence and  mortality  rates  of  colorectal  cancers 
for  white  males  and  females  in  Louisiana  were 
similar  to  the  national  estimates  provided  by  the 
Surveillance,  Epidemiology  and  End  Results 
(SEER)  program13  while  for  African-American 
males  and  females,  incidence  rates  in  Louisiana 
were  much  lower  than  the  national  estimates 
and  mortality  rates  were  about  the  same  as  the 
national  estimates.1719  Therefore,  the  incidence- 
to-mortality  (I/M)  rate  ratios  in  Louisiana  are 
comparable  to  the  national  levels  for  white 
males  and  females  but  substantially  lower  in 
Louisiana  than  nationally  for  African  Ameri- 
cans, especially  for  males,  reflecting  worse  sur- 
vival here.  More  advanced  stage  distributions 
in  Louisiana  patients  with  colorectal  cancer  may 
explain  partly  the  incidence  / mortality  discrep- 
ancies.19'21 An  earlier  study  shows  that  41%  of 
colorectal  cancer  among  whites  and  30%  among 
African  Americans  in  Louisiana  in  1983-1987 
were  diagnosed  before  they  had  invaded  adja- 
cent tissue  or  regional  lymph  nodes  while  in  the 
SEER  areas,  the  corresponding  percentages  were 
42%  and  37%. 19 

This  study  examines  1992-1996  incidence, 
mortality,  I/M  rate  ratios,  and  stage  distribu- 
tions and  compares  them  with  the  national  data. 
Stage  data  from  two  periods,  1988-1991  and 
1992-1996,  are  also  compared  among  eight  Loui- 
siana regions  to  determine  if  any  improvement 
in  stage  of  disease  at  diagnosis  for  colorectal 
cancer  has  occurred  as  awareness  of  colorectal 
cancer  screening  has  increased.  All  analyses  are 


presented  by  race  (whites  and  African  Ameri- 
cans) and  by  Louisiana  regions  to  help  identify 
target  populations  or  areas  for  enhanced 
colorectal  cancer  screening  programs. 

METHODS 

The  Louisiana  Tumor  Registry  (LTR)  divides  the 
state  into  eight  geographic  regions,  based  on 
historic  health  districts:  New  Orleans,  Baton 
Rouge,  Southeast,  Acadiana,  Southwest,  Central, 
Northwest,  and  Northeast.22  Average  annual 
population  estimates,  1992-1996,  for  each  region 
and  the  parishes  that  each  of  them  covered  are 
presented  in  Table  1. 

Cancer  incidence  data  for  Louisiana  were  ob- 
tained from  the  LTR  and  mortality  data  for  Loui- 
siana from  the  Vital  Statistics  Section  of  the  Of- 
fice of  Public  Health  in  the  Department  of  Health 
and  Hospitals  in  Louisiana.  Population  data 
were  from  the  US  Census  Bureau.  Incidence  data 
from  the  SEER  program,  which  were  provided 
by  the  National  Cancer  Institute  (NCI),  were 
used  as  a national  comparison  group.  This  pro- 
gram includes  five  states  (Connecticut,  Hawaii, 
Iowa,  New  Mexico,  and  Utah)  and  four  metro- 
politan areas  (Atlanta,  Detroit,  San  Francisco  Bay 
Area,  and  Seattle).  The  SEER  registries  cover 
about  10%  of  the  US  population  and  their  can- 
cer incidence  rates  are  often  reported  as  "na- 
tional averages".13  Mortality  data,  compiled  by 
the  National  Center  for  Health  Statistics  (NCHS), 
include  data  from  all  states  in  the  United  States 
Only  the  underlying  cause  of  death  was  used  in 
the  calculation  of  mortality  rates. 

Both  in  situ  and  invasive  colorectal  cancer 
cases  were  used  for  this  study.  Only  invasive 
cases  were  used  for  calculating  incidence  rates 
in  order  to  maintain  comparability  with  the  na- 
tional data.  All  colorectal  cancers  were  coded 
using  the  International  Classification  of  Disease  for 
Oncology  (ICD-O-2  )23  codes  C180-C189,  C260, 
Cl 99,  C209.  Lymphomas  in  the  colorectum  were 
excluded. 

All  colorectal  cancers  were  staged  according 
to  the  Summary  Staging  Guide.2*  The  subgroups 


172  J La  State  Med  Soc  VOL  152  April  2000 


Cancer  in  Louisiana 


Table  1.  Regions  of  the  Louisiana  Tumor  Registries 

Regional 

Registries 

1992-1996 

Average  Annual  Population1 

Parishes 

Covered 

All  races 

Whites 

African  Americans 

New  Orleans 

1,004,946 

586,474 

391,791 

Jefferson,  Orleans,  St 
Bernard 

Baton  Rouge 

767,663 

505,807 

252,948 

Ascension,  Assumption, 

East  Baton  Rouge,  East 
Feliciana,  Iberville,  Livingston, 
Pointe  Coupee,  St  Helena, 
Tangipahoa,  West  Baton 
Rouge,  West  Feliciana 

Southeast  Louisiana 

530,723 

411,766 

106,753 

Lafourche,  Plaquemines, 

St  Charles,  St  James,  St  John, 
St  Tammany,  Terrebonne, 
Washington 

Acadiana 

572,929 

405,753 

159,788 

Acadia,  Evangeline,  Iberia, 
Lafayette,  St  Landry,  St  Martin, 
St.  Mary,  Vermilion 

Southwest  Louisiana 

268,911 

207,564 

59,298 

Allen,  Beauregard,  Calcasieu, 
Cameron,  Jefferson  Davis 

Central  Louisiana 

305,126 

219,005 

81,727 

Avoyelles,  Catahoula,  Concordia, 
Grant,  LaSalle,  Rapides,  Vernon, 
Winn 

Northwest  Louisiana 

505,128 

316,102 

184,224 

Bienville,  Bossier,  Caddo, 
Claiborne,  DeSoto, 
Natchitoches,  Red  River, 
Sabine,  Webster 

Northeast  Louisiana 

351,147 

223,454 

125,632 

Caldwell,  East  Carroll,  Franklin, 
Jackson,  Lincoln,  Madison, 
Morehouse,  Ouachita,  Richland, 
Tensas,  Union,  West  Carroll 

Louisiana 

4,306,572 

2,875,926 

1,362,161 

1 Source:  US  Census  Bureau 

J La  State  Med  Soc  VOL  152  April  2000  173 


Cancer  in  Louisiana 


of  the  regional  category  for  Summary  Stage  were 
collapsed  in  this  study,  resulting  in  five  major 
stage  groups:  in  situ,  localized,  regional,  distant, 
and  unknown.  In  situ  disease  is  defined  as  tu- 
mors that  have  not  penetrated  the  basement 
membrane  of  the  colorectum.  Localized  disease 
describes  tumors  confined  entirely  to  the 
colorectum  while  regional  disease  extends  be- 
yond colorectum  directly  into  the  surrounding 
tissues,  organs,  or  regional  lymph  nodes.  Dis- 
tant disease  refers  to  tumors  that  have  metasta- 
sized to  other  areas  of  the  body. 

Incidence  and  mortality  rates  for  Louisiana, 
each  Louisiana  region,  and  the  SEER  areas  were 
age-adjusted  to  the  1970  US  population  to  re- 
move the  effect  of  differences  in  the  age  distri- 
butions among  populations.  All  rates  are  ex- 
pressed as  cases  per  100,000  at  risk.  The  ratios  of 
age-adjusted  incidence  rates  to  mortality  rates 
were  computed  as  well.  The  incidence /mortal- 
ity (I/M)  rate  ratio  is  a crude  measure  of  sur- 


vival. An  I / M rate  ratio  that  approximates  one 
indicates  extremely  poor  survival.  The  higher 
the  I/M  ratio,  the  better  the  survival. 

Stage  distributions  in  two  periods,  1988-1991 
and  1992-1996,  also  were  examined.  The  distri- 
butions were  calculated  using  the  cases  with 
known  stage  as  the  denominator.  Percentages 
of  unstaged  cases  were  calculated  using  all  cases 
as  the  denominator. 

RESULTS 

A total  of  848  in  situ  and  10,678  new  invasive 
colorectal  cancer  cases  were  diagnosed  in  Loui- 
siana in  1992-1996,  averaging,  approximately, 
2,300  cases  per  year.  Whites  accounted  for  74.5% 
of  the  total,  African  Americans  24.5%,  other 
races  0.52%,  and  unknown  races  0.40%.  Total 
counts  of  colorectal  cases  and  deaths  in  1992- 
1996  by  Louisiana  region  are  presented  in  Table  2. 


Table  2.  Colorectal  Cancer  Incident  Cases  and  Deaths  by  Louisiana  Region,  1992-1996 

Registries 

Number  of  Incident  Cases 

Number  of  Deaths 

In  situ 

Invasive 

New  Orleans 

293 

2,746 

1,203 

Baton  Rouge 

132 

1,714 

674 

Southeast  Louisiana 

91 

1,120 

448 

Acadiana 

89 

1,321 

547 

Southwest  Louisiana 

34 

667 

292 

Central  Louisiana 

31 

728 

319 

Northwest  Louisiana 

109 

1,489 

650 

Northeast  Louisiana 

69 

893 

394 

Louisiana 

848 

10,678 

4,527 

174  J La  State  Med  Soc  VOL  152  April  2000 


Cancer  in  Louisiana 


Incidence  and  mortality  rates  and 
I/M  rate  ratios 

Table  3 details  the  incidence  and  mortality  rates 
by  race,  sex,  and  geographic  region.  In  1992-1996, 
age-adjusted  incidence  and  mortality  rates  for 
Louisiana  white  females  (37.1  per  100,000  and 
14.6  respectively)  were  similar  to  national  lev- 
els (37.1  and  14.2  respectively).  For  white  males 
in  Louisiana,  although  the  age-adjusted  inci- 
dence rate  was  statistically  significantly  higher 


than  in  the  SEER  areas  (55.1  per  100,000  and  52.8 
respectively),  their  mortality  rate  was  about  the 
same  as  nationally  (21.4  and  21.1  respectively). 
In  contrast,  African  Americans  experienced  com- 
parable mortality  rate  (28.0  per  100,000  in  Loui- 
siana and  27.6  in  the  United  States)  for  males 
and  slightly  lower  mortality  rate  (18.9  per 
100,000  in  Louisiana  and  19.8  in  the  United 
States)  for  females  even  though  their  incidence 
rates  were  statistically  significantly  lower  than 
in  the  United  States  (53.6  per  100,000  for  males 


Table  3.  Age-adjusted  (1970)  Incidence  and  Mortality  Rates  and  Mortality  Rate  Ratios  and  Stage  Distri- 
butions for  Colorectal  Cancer  by  Region  of  Residence  and  Race.  1992-1996 


Males 

Females 

Inc.  Rate 

Mort.  rate 

LM 

Inc.  Rate 

Mort.  rate 

LM 

SEER 

White 

52.8 

21.1 

2.50 

37.1 

14.2 

2.61 

Black 

57.6 

27.6 

2.09 

44.5 

19.8 

2.25 

Louisiana 

White 

55.1 

* 

21.4 

2.57 

37.1 

14.6 

2.54 

Black 

53.6 

* 

28.0 

1.91 

41.6  * 

18.9 

2.20 

New  Orleans 

White 

58.1 

* 

22.9 

2.54 

39.1 

16.3  * 

2.40 

Black 

58.2 

33.1 

* 

1.76 

46.2 

19.6 

2.36 

Baton  Rouge 

White 

56.2 

20.2 

2.78 

36.6 

13.9 

2.63 

Black 

56.8 

27.0 

2.10 

43.8 

19.3 

2.27 

Southeast  Louisiana 

White 

57.8 

22.5 

2.57 

36.1 

13.6 

2.65 

Black 

49.0 

29.8 

1.64 

31.0  * 

13.5  * 

2.30 

Acadiana 

White 

50.7 

20.1 

2.52 

37.3 

13.8 

2.70 

Black 

57.8 

24.2 

2.39 

39.9 

20.8 

1.92 

Southwest  Louisiana 

White 

54.5 

24.2 

* 

2.25 

34.2 

14.1 

2.43 

Black 

43.1 

* 

23.3 

* 

1.85 

47.7 

18.9 

2.52 

Central  Louisiana 

White 

50.8 

20.9 

2.43 

35.1 

13.0 

2.70 

Black 

49.4 

27.5 

1.80 

39.5 

21.1 

1.87 

Northwest  Louisiana 

White 

56.7 

21.7 

2.61 

39.1 

16.1  * 

2.43 

Black 

55.7 

29.2 

1.91 

39.7 

17.8 

2.23 

Northeast  Louisiana 

White 

52.3 

19.1 

2.74 

35.5 

13.6 

2.61 

Black 

41.2 

* 

22.6 

* 

1.82 

38.6 

20.0 

1.93 

* Rate  is  statistically  significantly  different  (P  = .05)  from  the  rate  in  the  SEER  areas. 


J La  State  Med  Soc  VOL  152  Apri  2000  175 


Cancer  in  Louisiana 


and  41.6  for  females  in  Louisiana  compared  with 
57.6  for  males  and  44.5  respectively  in  the  SEER 
areas).  The  I/M  rate  ratios  were  lower  in  Loui- 
siana than  in  the  SEER  areas  for  all  race-sex 
groups  except  for  white  males.  Of  interest  is  the 
higher  absolute  difference  in  the  I/M  rate  ratios 
between  the  SEER  areas  and  Louisiana  African- 
American  males  than  in  other  race-sex  groups. 

Generally,  incidence  rates  of  colorectal  can- 
cer for  whites  were  not  statistically  significantly 
different  in  Louisiana  regions  from  the  rates  in 
the  SEER  areas  except  for  white  males  in  the 
New  Orleans  region,  where  the  incidence  rate 
was  significantly  higher.  In  contrast,  incidence 
rates  were  statistically  significantly  lower  in 
Southwest  Louisiana  for  African-American 
males,  and  in  Southeast  Louisiana  for  African- 
American  females.  Mortality  rates  were  statisti- 
cally significantly  higher  in  Southwest  Louisi- 
ana for  white  males  and  in  the  New  Orleans  re- 
gion for  white  females  than  in  the  United  States. 
For  African-American  males  in  the  New  Orleans 
region,  although  their  incidence  rate  was  not  sig- 
nificantly different  from  the  rate  in  the  SEER 
areas,  the  mortality  rate  was  significantly  higher 
than  in  the  United  States.  For  African-American 
males  in  Southwest  and  Northeast  Louisiana 
and  African-American  females  in  Southeast 
Louisiana,  corresponding  to  their  low  incidence 
rates,  their  mortality  rates  were  also  significantly 
lower  than  the  rates  in  the  United  States.  The 
I/M  rate  ratios  also  varied  by  Louisiana  region. 
The  I/M  rate  ratios  for  white  males  were  slightly 
lower  in  four  Louisiana  regions  (New  Orleans, 
Acadiana,  Southwest,  Central)  than  in  the  SEER 
areas,  and  for  white  females  they  were  lower  in 
three  Louisiana  regions  (New  Orleans,  South- 
west, Northwest).  For  African-American  males, 
the  I/M  rate  ratios  were  lower  in  all  Louisiana 
regions  except  Acadiana  and  Baton  Rouge 
whereas  for  African-American  females,  only 
Northeast  and  Northwest  Louisiana  and 
Acadiana  had  lower  I/M  rate  ratios  than  the 
SEER  areas.  Overall,  the  1/  M rate  ratios  for  males 
were  lower  for  African  Americans  than  for 
whites  in  all  Louisiana  regions,  and  for  females. 


they  were  lower  for  African  Americans  than  for 
whites  in  all  but  Southwest  Louisiana  and  the 
New  Orleans  region. 

Stage  of  disease  at  diagnosis 

At  diagnosis,  Louisiana  patients  with  colorectal 
cancer  had  slightly  lower  percentages  of  early 
stage  disease  than  did  the  patients  in  the  SEER 
areas  and,  paradoxically,  Louisiana  patients  also 
had  slightly  lower  proportions  of  distant  dis- 
ease (Table  4).  Louisiana  white  females  were 
slightly  less  likely  to  be  diagnosed  with  early 
stage  of  disease  than  were  Louisiana  white 
males  whereas  the  reverse  pattern  prevailed 
among  African  Americans. 

Although  stage  distributions  for  Louisiana 
as  a whole  were  not  very  different  from  those  in 
the  SEER  areas,  the  distributions  varied  mark- 
edly by  Louisiana  region  in  1992-1996.  Percent- 
ages of  in  situ  and  localized  disease  combined 
ranged  from  40.4%  in  the  Baton  Rouge  area  to 
47.2%  in  Southeast  Louisiana  for  whites  and 
from  34.6%  in  Southeast  Louisiana  to  45.7%  in 
Central  Louisiana  for  African  Americans,  and 
percentages  of  distant  disease  ranged  from 
11.8%  in  Southwest  Louisiana  to  20.0%  in  Baton 
Rouge  for  whites  and  from  12.0%  in  Southwest 
Louisiana  and  26.4%  in  Southeast  Louisiana  for 
African  Americans  (Table  5).  Overall,  white  pa- 
tients had  a higher  chance  than  African-Ameri- 
can patients  of  being  diagnosed  with  early  stage 
of  disease  (in  situ  & localized)  in  1992-1996  ex- 
cept in  Acadiana  and  Central  Louisiana,  and  the 
percentages  of  African-American  patients  diag- 
nosed with  distant  disease  were  also  higher  than 
white  patients  in  all  Louisiana  regions. 

Stage  of  disease  at  diagnosis  in  Louisiana  has 
improved  slightly  from  1988-1991  to  1992-1996. 
This  trend  was  more  pronounced  for  whites  than 
for  African  Americans.  For  white  patients,  the 
percentage  of  early  stage  of  disease  (in  situ  & 
localized)  increased  from  40.6%  to  43.2%.  For 
African  Americans,  it  increased  only  from  37.7% 
to  38.7%.  Although  this  improvement  was  found 
in  Louisiana  combined  data,  it  was  not  observed 
in  all  Louisiana  regions.  The  percentages  of  early 


176  J La  State  Med  Soc  VOL  152  April  2000 


Cancer  in  Louisiana 


Table  4.  Stage  Distributions  of  Colorectal  Cancer  in  Louisiana  and  the  SEER  areas,  1992-1996 


In  situ  & Localized 

Regional 

Distant 

Unstaged1 

Both  Sexes 

SEER 

White 

44.5 

36.9 

18.6 

(6.2) 

Black 

40.4 

36.0 

23.5 

(7.5) 

Louisiana 

White 

43.2 

39.0 

17.8 

(6.7) 

Black 

38.7 

38.9 

22.3 

(9.4) 

Males 

SEER 

White 

45.6 

35.7 

18.8 

(6.2) 

Black 

40.9 

35.7 

23.4 

(7.5) 

Louisiana 

White 

44.3 

37.4 

18.3 

(6.4) 

Black 

38.2 

38.4 

23.4 

(9.6) 

Females 

SEER 

White 

43.5 

38.2 

18.3 

(6.2) 

Black 

40.1 

36.3 

23.6 

(7.5) 

Louisiana 

White 

42.1 

40.6 

17.3 

(7.1) 

Black 

39.2 

39.4 

21.4 

(9.2) 

‘Items  in  parentheses  indicate  the  percentage  of  the  total.  Otherwise,  the  percentages  refer  to  cases  with  known  stage  cases. 


stage  disease  declined  in  Acadiana  for  whites 
and  in  Southeast  Louisiana  and  Acadiana  for 
African  Americans. 

DISCUSSION 

The  incidence /mortality  rate  ratio  of  colorectal 
cancer  for  African-American  males  was  substan- 
tially lower  in  Louisiana  than  in  the  SEER  areas. 
Because  the  I/M  rate  ratio  serves  as  a crude 
measure  of  survival,  a lower  I/M  rate  ratio  for 
African-American  males  may  reflect  poor  sur- 
vival. Moreover,  although  all  race-sex  groups  in 
Louisiana  had  slightly  lower  proportions  of  early 
stage  of  disease  than  in  the  SEER  areas,  the  dif- 


ference in  the  proportion  of  early  stage  disease 
between  Louisiana  and  SEER  areas  was  more 
pronounced  for  African-American  males.  This 
may  imply  that  the  poorer  survival  observed  in 
African-American  males  in  Louisiana  is  due  to 
a more  advanced  stage  of  disease.  Although 
early  diagnosis  of  colorectal  cancer  increased  in 
most  Louisiana  regions  from  1988-1991  to  1992- 
1996,  some  regions  had  lower  percentages  of 
early  stage  cases  than  the  state  as  a whole  or 
showed  declines  in  early  diagnosis.  A 1997  sur- 
vey by  Behavioral  Risk  Factor  Surveillance  Sys- 
tem (BRFSS)  found  that  the  percentages  of  re- 
spondents aged  50  and  older  who  reported  hav- 
ing a proctoscopic  or  sigmoidoscopic  examina- 


J La  State  Med  Soc  VOL  152  April  2000  177 


Cancer  in  Louisiana 


Table  5.  Distributions  of  Stage  of  Disease  at  Diagnosis  for  Colorectal  Cancer  in  Two  Periods  in  Louisiana 

Whites 

African  Americans 

In  situ  & 

Regional 

Distant 

Unstaged1 

In  situ  & 

Regional 

Distant  Unstaged1 

Localized 

Localized 

Louisiana 

1988-1991 

40.6 

41.2 

18.2 

(5.5) 

37.7 

37.7 

24.7 

(8-3) 

1992-1996 

43.2 

39.0 

17.8 

(6.7) 

38.7 

38.9 

22.3 

(9.4) 

New  Orleans 
1988-1991 

40.1 

41.9 

17.9 

(3.8) 

37.7 

38.2 

24.2 

(6.8) 

1992-1996 

43.7 

38.2 

18.1 

(6.0) 

37.9 

39.7 

22.5 

(9.7) 

Baton  Rouge 
1988-1991 

39.6 

41.8 

18.6 

(5.7) 

31.3 

41.7 

27.0 

(7.9) 

1992-1996 

40.4 

39.6 

20.0 

(6.6) 

35.1 

39.1 

25.8 

(7.6) 

Southeast  Louisiana 
1988-1991 

42.3 

41.4 

16.3 

(4.0) 

46.7 

39.4 

13.9 

(4.9) 

1992-1996 

47.2 

34.8 

18.0 

(6.4) 

34.6 

39.0 

26.4 

(7.0) 

Acadiana 

1988-1991 

48.2 

33.3 

18.5 

(6.0) 

47.5 

30.0 

22.5 

(7.4) 

1992-1996 

40.6 

40.9 

18.6 

(6.5) 

41.6 

38.6 

19.8 

(6.3) 

Southwest  Louisiana 
1988-1991 

42.4 

40.2 

17.4 

(7.8) 

37.6 

33.3 

29.0 

(9.7) 

1992-1996 

46.5 

41.7 

11.8 

(7.6) 

44.4 

43.5 

12.0 

(8.5) 

Central  Louisiana 
1988-1991 

31.1 

47.9 

21.0 

(9.6) 

42.7 

29.2 

28.1 

(14.3) 

1992-1996 

42.8 

39.5 

17.7 

(9.4) 

45.7 

34.8 

19.6 

(12.1) 

Northwest  Louisiana 
1988-1991 

37.6 

42.4 

20.0 

(6.6) 

38.4 

39.1 

22.6 

(10.9) 

1992-1996 

42.3 

40.9 

16.8 

(6.8) 

41.4 

38.3 

20.3 

(10.1) 

Northeast  Louisiana 
1988-1991 

39.8 

43.6 

16.5 

(5.0) 

27.1 

40.6 

32.4 

(9.1) 

1992-1996 

44.6 

37.4 

18.0 

(6.7) 

36.2 

38.1 

25.7 

(14.8) 

Ttems  in  parentheses  indicate  the  percentage  of  the  total.  Otherwise,  the  percentages  refer  to  cases  with 

known  stage  cases. 

178  J La  State  Med  Soc  VOL  152  April  2000 


Cancer  in  Louisiana 


tion  during  the  preceding  5 years  in  Louisiana 
was  26.2%,  compared  with  the  national  average 
of  30.4%.  Louisiana  ranked  the  forty-second  out 
of  50  states  and  the  District  of  Columbia.16  More 
aggressive  screening  for  colorectal  cancer  appar- 
ently needs  to  be  promoted  in  Louisiana,  espe- 
cially in  the  regions  with  lower  prevalence  of 
early  stage  disease  or  lower  I/M  rate  ratios,  since 
the  screening  for  colorectal  cancer  is  directly  re- 
lated to  the  percentage  of  early  stage  diag- 
noses.20-21 

Racial  differences  in  the  I/M  rate  ratios  and 
stage  distributions  continue  to  indicate  that  Af- 
rican Americans  were  more  likely  than  whites 
to  be  diagnosed  with  more  advanced  disease  and 
experienced  worse  prognosis  in  most  Louisiana 
regions.  Although  the  National  Health  Interview 
Survey  documented  an  increase  in  the  use  of 
early  detection  procedures  such  as  proctoscopy 
and  fecal  occult  blood  test  (FOBT)  among  Afri- 
can Americans  between  1987  and  1992,  the  use 
of  these  procedures  still  was  lower  among  Afri- 
can Americans  than  among  whites.20'25  The  1992- 
1993  Behavioral  Risk  Factor  Surveillance  System 
also  reported  lower  percentages  of  proctoscopy 
among  African  Americans  than  among  whites.26 
The  reasons  for  lower  screening  among  African 
Americans  may  include  lack  of  information  on 
the  availability  and  benefits  of  earlv-detection 
procedures  and  the  presence  of  economic  barri- 
ers.2-22- Because  screening  can  lower  the  num- 
ber of  cases  and  also  impact  the  death  rate,1'3 
further  reduction  of  colorectal  cancer  incidence 
and  mortality  in  Louisiana  warrants  enhanced 
screening  for  colorectal  cancer,  especially  among 
African  Americans,  in  addition  to  risk  factor  re- 
duction. 

REFERENCES 

1 . Gilbertsen  VA.  Proctosigmoidoscopy  and  polypec- 
tomy in  reducing  the  incidence  of  rectal  cancer. 

Cancer  1974;34  (suppl):936-939. 

2.  Winawer  SJ,  Zauber  AG,  Ho  MN,  et  al.  Prevention 

of  colorectal  cancer  by  colonoscopic  polypectomy. 

N Engl  J Med  1993;329:1977-1981. 


3.  Thiis-Evensen  E,  Hoff  GS,  Sauar  J,  et  al.  Popula- 
tion-based surveillance  by  colonoscopy:  effect  on 
the  incidence  of  colorectal  cancer.  Telemark  Polvp 
Study  I.  Scand  J Gastroenterol  1999;34:414-420. 

4.  Haxdcastle  JD,  Chamberlain  JO,  Robinson  MH,  et 
al.  Nottingham  randomized  controlled  trial  of  fe- 
cal-occult-blood  screening  for  colorectal  cancer. 
Lancet  1996;348:1472-1477. 

5.  Kronborg  O,  Fenger  C,  Olsen  J,  et  al.  Randomized 
study  of  screening  for  colorectal  cancer  with  fecal- 
occult-blood  test.  Lancet  1996;348:1467-1471. 

6.  Selby  JV,  Friedman  GD,  Quesenberry  CP  Jr,  et  al. 
Effect  of  fecal  occult  blood  testing  on  mortality"  from 
colorectal  cancer:  a case  control  study'.  Ann  Intern 
Med  1993;118:1-6. 

7.  Wahrendorf  J,  Robra  B-P,  Wiebelt  H,  et  al.  Effec- 
tiveness of  colorectal  cancer  screening:  results  from 
a population-based  case-control  evaluation  in 
Saarland,  Germany.  Enr  J Cancer  Prev  1993;2:221- 
227. 

8.  Selby  JV,  Friedman  GD,  Quesenberry',  CP  Jr,  et  al. 
A case-control  study  of  screening  sigmoidoscopy 
and  mortality  from  colorectal  cancer.  N Engl  J Med 
1992;326:653-657. 

9.  Newcomb  PA,  Norfleet  RG,  Storer  BE,  et  al.  Screen- 
ing sigmoidoscopy  and  colorectal  cancer  mortal- 
ity. J Natl  Cancer  Inst  1992;84:1572-1575. 

10.  Parkin  DM,  Pisani  P,  Ferlay  J.  Estimates  of  the 
worldwide  incidence  of  eighteen  major  cancers  in 
1985.  Inter  J Cancer  1993;54:594-606. 

11.  Stryker  SJ,  Wolff  BG,  Gulp  CE,  et  al.  Natural  his- 
tory' of  untreated  colonic  polvps.  Gastroentrology 
1987;93:1009-1013. 

12.  Winawer  SJ.  Natural  history'  of  colorectal  cancer. 
Am  J Med  1999;106:3S-6S. 

13.  Ries  LAG,  Kosary  CL,  Hankev  BF,  et  al  (editors). 
SEER  Cancer  Statistics  Review,  1973-1996.  Bethesda, 
Md:  National  Cancer  Institute;  1999.  [NTH  Pub.  No. 
99-2789], 

14.  Byers  T,  Le\Tn  B,  Rothenberger  D,  et  al.  American 
Cancer  Society  guidelines  for  screening  and  sur- 
y^eillance  for  early  detection  of  colorectal  polyps 
and  cancer:  update  1997.  American  Cancer  Society 
Detection  and  Treatment  Ady'isorv  Group  on 
Colorectal  Cancer.  CA  Cancer  J Clin  1997;47:154-160. 

15.  Winawer  SJ,  Hetcher  RH,  Miller  L,  et  al.  Colorectal 
cancer  screening:  clinical  guidelines  and  rationale. 
Gastroenterology  1997;112:594-642. 

16.  CDC.  Screening  for  colorectal  cancer  in  the  United 
States,  1997.  MMWR  1999;48:116-121. 

17.  Andrew's  PA,  Correa  CN,  Wu  XC,  et  al.  Cancer  Inci- 
dence and  Mortality  in  Louisiana,  1990-1994.  New"  Or- 


J La  State  Med  Soc  VOL  152  April  2000  179 


Cancer  in  Louisiana 


leans:  Louisiana  Tumor  Registry;  1998.  (Cancer  in 
Louisiana;  Vol.  10). 

18.  Ries  LAG,  Kosary  CL,  Hankey  BF,  et  al  (editors). 
SEER  Cancer  Statistics  Review , 1973-1994.  Bethesda, 
Md:  National  Cancer  Institute;  [NIH  Pub.  No.  97- 
2789.] 

19.  Chen  VW,  Wu  XW,  Andrews  P,  et  al.  Advanced 
stage  at  diagnosis:  an  explanation  for  higher  than 
expected  cancer  death  rates  in  Louisiana.  J La  State 
Med  Soc  1994;146:137-145. 

20.  Chu  KC,  Tarone  RE,  Chow  WH,  et  al.  Colorectal 
cancer  trends  by  race  and  anatomic  subsites,  1975 
to  1991.  Arch  Earn  Med  1995;4:849-856. 

21.  Troisi  RJ,  Freedman  AN,  Devesa  SS.  Incidence  of 
colorectal  carcinoma  in  the  U.S.:  an  update  of  trends 
by  gender,  race,  age,  subsite,  and  stage,  1975-1994. 
Cancer  1999;85:1670-1676. 

22.  Chen  VW,  Wu  XW,  Ahmed  MN,  et  al.  Cancer  of 
the  colon  and  rectum  in  Louisiana.  J La  State  Med 
Soc  1999;151:189-197. 

23.  Percy  C,  Van  Holten,  Muir  C.  International  Classifi- 
cation of  Diseases  for  Oncology.  2nd  edition.  Geneva, 
Switzerland:  World  Health  Organization;  1990. 

24.  SEER.  Summary  Staging  Guide  for  the  Cancer  Surveil- 
lance, Epidemiology  and  End  Results  Reporting  (SEER) 
program.  Bethesda:  National  Institutes  of  Health; 
April  1977.  [Reprinted  July  1986.  NIH  Pub.  No.  86- 
2313.] 

25.  Jepson  C,  Kessler  LG,  Portnoy  B,  et  al.  Black-white 
differences  in  cancer  prevention  knowledge  and 
behavior.  Am  J Public  Health  1991;81:501-504. 

26.  CDC.  Screening  for  colorectal  cancer  - United 
States,  1992-1993,  and  new  guidelines.  MMWR 
1996;45:107-110. 

27.  Baquet  CR,  Horm  JW,  Gibbs  T,  et  al.  Socioeconomic 
factors  and  cancer  incidence  among  blacks  and 
whites.  J Natl  Cancer  Inst  1991;83:551-557. 

28.  Freeman  HP.  Cancer  in  the  socioeconomically  dis- 
advantaged. CA  Cancer  J Clin  1989;39:266-288. 


All  authors  are  faculty  members  in  the 
Department  of  the  Public  Health  & 
Preventive  Medicine,  Louisiana  State  University  Health 
Sciences  Center,  New  Orleans,  Louisiana. 

Drs  Ahmed , Chen,  Wu,  and  Correa,  Ms  Andrews,  and 
Ms  Schmidt  are  also  the  central  staff  of  the  Louisiana 
Tumor  Registry,  New  Orleans,  Louisiana. 

Drs  Chen  and  Fontham  are  members  of  the 
Stanley  S.  Scott  Cancer  Center, 
LSU  Health  Sciences  Center, 
New  Orleans,  Louisiana. 


180  J La  State  Med  Soc  VOL  152  April  2000 


Cancer  in  Louisiana 


Long  Term  Survival  of  Mice  that  Express 
Dominant  Negative  p53  in  the  Lung 

Tamra  Mendoza,  BS;  Anne  B.  Nelson,  PhD;  Sushmita  Ghosh,  PhD; 

Cindy  B.  Morris,  PhD;  Gary  W.  Hoyle,  PhD;  Arnold  R.  Brody,  PhD; 

Mitchell  Friedman,  MD;  and  Gilbert  F.  Morris,  PhD 

To  develop  a mouse  model  for  the  study  of  human  lung  cancer,  transgenic  mice  were 
prepared  that  express  a "dominant  negative"  mutant  form  of  the  human  p53  tumor 
suppressor  protein  from  the  human  surfactant  protein  C (SPC)  promoter  (SPC-DNp53  mice). 
The  dominant  negative  p53  protein  can  compromise  normal  p53  function  in  the  lung  and 
thereby  promote  lung  tumorigenesis.  SPC-DNp53  transgenic  mice  displayed  no  obvious 
increase  in  morbidity  or  mortality  relative  to  nontransgenic  littermates  over  an  observation 
period  of  18  months.  To  accelerate  the  incidence  and  rate  of  lung  tumorigenesis,  groups  of 
the  SPC-DNp53  transgenic  animals  and  nontransgenic  littermates  were  exposed  once  for  5 
hours  to  an  aerosol  of  asbestos.  There  was  no  clear  decrease  in  survival  of  asbestos-exposed 
transgenic  mice  relative  to  nontransgenic  littermates.  Although  some  transgenic  mice 
displayed  suspicious  lung  lesions,  these  observations  suggest  that  expression  of  dominant 
negative  p53  in  the  lung  does  not  dramatically  reduce  the  survival  of  mice. 


Lung  cancer  is  the  leading  cause  of  can 
cer-related  death1  and  the  incidence  of 
lung  cancer  in  the  state  of  Louisiana  is 
significantly  higher  than  the  national  average.2 
The  high  mortality  of  lung  cancer  is  attributed 
to  the  advanced  stage  of  the  disease  at  the  time 
of  diagnosis,  the  inadequacy  of  current  thera- 
pies, and  the  aggressive  characteristics  of  the  dis- 
ease. Tobacco  use  correlates  with  most  lung  can- 
cer cases  and  carcinogens  in  tobacco  smoke 
likely  account  for  the  multiple  genetic  alterations 
of  human  lung  cancers.  Exposure  to  asbestos 
also  increases  the  incidence  of  various  cancers 
in  humans.  Animal  models  must  be  developed 
to  understand  the  mechanisms  of  the  initiation 
and  progression  to  lung  cancer.  The  introduc- 
tion of  tumor  promoting  genes  into  mice  by 


transgenic  means  provides  an  approach  to 
model  the  genetic  alterations  of  human  lung 
cancers  in  mice  and  thereby  to  understand  neo- 
plastic processes  in  the  lung. 

Approximately  half  of  human  lung  tumors 
display  mutations  in  the  gene  encoding  the  p53 
tumor  suppressor  protein.3  A recent  report  link- 
ing the  spectrum  of  mutations  in  the  p53  gene 
elicited  by  a component  of  tobacco  smoke  with 
similar  mutations  in  the  p53  gene  found  in  hu- 
man lung  cancers  suggests  a causal  relationship 
in  lung  cancer  pathogenesis.4  The  detection  of 
mutant  p53  protein  at  high  frequency  in  neo- 
plastic tissues  suggests  selection  for  mutations 
that  preserve  expression  of  an  altered  p53  pro- 
tein. Many  of  the  mutations  in  p53  that  com- 
monly occur  in  human  tumors  are  base  substi- 


J La  State  Med  Soc  VOL  152  April  2000  181 


Cancer  in  Louisiana 


tutions  within  a domain  of  the  protein  that  in- 
terferes with  DNA  binding.5  The  ability  of  these 
p53  mutant  proteins  to  form  complexes  with  the 
wild-type  protein  and  consequently  inhibit  DNA 
binding  suggests  a mechanism  for  a dominant 
negative  activity  that  leads  to  a selective  growth 
advantage  for  neoplastic  tissue.5 

Expression  of  a dominant  negative  mutant 
form  of  p53  from  a transgene  in  normal  mice 
promotes  tumorigenesis  in  about  20%  to  30%  of 
the  animals  with  a high  incidence  of  lung  ad- 
enocarcinomas.67 The  utility  of  these  mice  as  a 
lung  cancer  model  suffers  from  the  ubiquitous 
pattern  of  expression  of  the  dominant  negative 
p53  transgene,  which  leads  to  a high  incidence 
of  other  tumor  types,  particularly  lymphomas 
and  osteosarcomas,  and  early  mortality.67  To 
restrict  tumorigenesis  to  the  lung,  we  prepared 
two  lines  of  mice  harboring  a transgene  that  ex- 
presses a dominant  negative  mutant  form  of 
human  p53  from  a lung-specific  (surfactant  pro- 
tein C)  promoter.8  Over-expression  of  p53  was 
observed  by  immunoblotting  lung  extracts  pre- 
pared from  the  transgenic  animals.8  The  pat- 
tern of  p53  expression  in  the  transgenic  mice 
appeared  to  be  restricted  to  alveolar  type  II  cells 
and  to  pulmonary  epithelial  cells  of  the  small 
airways.8  We  compare  here  the  survival  of  co- 
horts from  the  two  transgenic  lines  that  over- 
express dominant  negative  p53  in  the  lung  with 
nontransgenic  littermates.  Transgenic  and 
nontransgenic  mice  exposed  briefly  to  an  aero- 
sol of  asbestos  also  displayed  similar  rates  of 
survival.  These  initial  observations  indicate  that 
dominant  negative  p53  expression  in  the  lung  is 
not  sufficient  to  induce  the  rapid  onset  of  lung 
malignancies  in  mice.  Thus,  we  conclude  that 
additional  alterations  are  required  for  lung  tu- 
mor development. 

METHODS 

Mice,  Asbestos  Exposure,  and  Tissue  Prepa- 
ration 

Preparation  of  the  70-2  and  70-3  transgenic  lines 
was  described  previously.8  Briefly,  transgenic 
mice  were  prepared  that  harbor  a DNA  construct 

182  J La  State  Med  Soc  VOL  152  April  2000 


with  the  human  surfactant  protein  C promoter 
(SPC)  directing  expression  of  a human  dominant 
negative  p53  protein  (arginine  to  histidine 
change  at  amino  acid  175).  In  all  crosses  of  sur- 
factant protein  C-dominant  negative  p53  (SPC- 
DNp53)  transgenic  mice,  one  parent  was  a 
B6SJLF2  mouse  that  harbored  the  transgene 
mated  to  a B6SJLF1  nontransgenic  mouse.  This 
cross  yields  approximately  equal  numbers  of 
SPC-DNp53  transgenic  mice  and  nontransgenic 
littermates  that  are  roughly  equal  genetic  mix- 
tures of  the  C57BL/6  and  SJL  inbred  strains. 
Transgenic  mice  and  nontransgenic  littermates 
from  both  transgenic  lines  were  exposed  "nose 
only"  for  a single  5-hour  period  to  an  aerosol  of 
asbestos  at  12.5  mg/  m3  in  an  enclosed  chamber.9 
Unexposed  and  asbestos-exposed  mice  were 
anesthetized  with  tribromoethanol  and  sacri- 
ficed by  exsanguination  for  gross  evaluation.  The 
lungs  of  each  animal  were  inflated  by  intratra- 
cheal perfusion  of  neutral  buffered  formalin.8 
After  30  minutes  perfusion,  the  lungs  and  heart 
were  removed  from  the  chest  and  stored  in  fixa- 
tive overnight.  The  next  day  the  lobes  of  the 
lungs  were  separated  and  inspected  closely  for 
lesions  before  being  placed  in  cassettes  for  par- 
affin embedding. 

Genotyping 

Transgenic  and  nontransgenic  mice  were  iden- 
tified by  dot  blotting  of  DNA  extracted  from 
mice  tails.  Briefly,  one  centimeter  of  the  tail  was 
clipped  from  each  mouse  and  digested  in  2 mil- 
liliters of  SET  buffer  plus  proteinase  K (lOmM 
Tris,  pH  7.5;  5mM  EDTA;  300mM  NaCl;  1%  SDS; 
0.5  mg  proteinase  K)  at  55°C  for  2 hours.  Debris 
was  removed  from  the  samples  by  centrifuga- 
tion at  3,000  rpm  for  10  minutes  in  a table  top 
clinical  centrifuge.  A 0.5  mL  aliquot  was  re- 
moved from  the  supernatant  and  precipitated 
by  adding  two  volumes  of  ethanol.  The  DNA 
pellet  was  collected  by  centrifugation  in  a 
microcentrifuge  and  the  supernatant  was  com- 
pletely removed.  The  DNA  pellet  was  resus- 
pended in  12  ]iL  of  2M  NaCl,  0.1M  NaOH  and 
incubated  for  10  minutes.  Then  the  samples  were 
boiled  for  3 minutes  before  spotting  5 }iL  of  each 
onto  gridded  nitrocellulose.  The  filters  were 


Cancer  in  Louisiana 


baked  in  vacuo  for  1-2  hours  at  80CC  before  pre- 
hybridization in  10  milliliters  50%  formamide, 
0.75M  sodium  chloride;  50mM  sodium  phos- 
phate, pH  7.4;  5mM  EDTA;  0.1%  ficol;  0.1%  poly- 
vinylpyrrolidone; 0.1%  SDS;  100  ^g/mL  dena- 
tured salmon  sperm  DNA  for  2 hours  at  42°C. 
The  probe  was  generated  from  the  isolated  hu- 
man surfactant  protein  C promoter  DNA  frag- 
ment by  random  priming  and  added  directly  to 
the  pre-hybridization  solution  for  overnight 
hybridization.10  After  hybridization,  the  blot  was 
washed  two  times  15  minutes  each  in  0.3M  so- 
dium chloride;  20mM  sodium  phosphate,  pH 
7.4;  2mM  EDTA;  0.1%  SDS  at  65°C  followed  by 
two  washes  30  minutes  each  in  15mM  sodium 
chloride;  ImM  sodium  phosphate,  O.lmM 
EDTA;  0.1%  SDS  at  65°C.  The  filter  was  then 
dried  and  exposed  to  x-ray  film. 

RESULTS 

The  SPC-DNp53  transgenic  mice  express  p53  at 
high  levels  in  the  lung.8  The  dominant  negative 


p53  used  to  ablate  p53  function  in  the  lung  epi- 
thelium of  our  transgenic  mice  has  an  arginine 
to  histidine  change  at  amino  acid  175  relative  to 
wild-type  human  p53.  Mutations  in  codon  175 
of  p53  occur  in  about  1.6%  of  the  identified  p53 
mutations  in  human  lung  tumors.11  The  argin- 
ine to  histidine  change  at  position  175  produces 
a highly  oncogenic  form  of  p53  that  possesses 
dominant  negative  and  gain  of  function  activ- 
ity.712 We  postulate  that  the  dominant  negative 
p53  expressed  from  the  SPC  promoter  will  an- 
tagonize wild-type  p53  functions  specifically  in 
the  lungs  of  the  transgenic  animals  and  promote 
development  of  carcinoma  of  the  lung. 

Mice  that  express  dominant  negative  p53 
(alanine  to  valine  change  at  position  135) 
throughout  the  body  develop  lung  adenocarci- 
noma with  an  onset  of  55  weeks."  Therefore,  to 
assess  the  relevance  of  the  SPC-DNp53 
transgenic  mice  as  a model  for  pulmonary 
neoplasias  in  humans,  we  evaluated  survival  of 
transgenic  mice  and  nontransgenic  littermates 
over  a period  of  18  months  (Figure  1).  During 
the  monitoring  period,  the  survival  of  transgenic 


Figure  1.  Groups  of  SPC-DNp53  transgenic  mice  (T)  and  nontransgenic  littermates  (NT)  in  lines  70-2  and  70-3 
were  monitored  for  survival  for  seventy-eight  weeks.  The  figure  shows  the  percentage  of  mice  in  each  group  that 
survived  for  the  indicated  period  in  weeks.  The  numbers  of  mice  monitored  for  survival  in  each  group  are  also 
shown.  The  solid  line  shows  the  survival  of  transgenic  mice  and  the  dashed  line  indicates  the  survival  of 
nontransgenic  littermates.  The  survival  curves  of  mice  in  the  70-2  line  are  indicated  by  circles  and  in  the  70-3  line 
by  squares. 


J La  State  Med  Soc  VOL  152  April  2000  183 


Cancer  in  Louisiana 


mice  in  the  70-3  line  (closed  squares.  Figure  1) 
appeared  equivalent  to  that  of  nontransgenic  lit- 
termates  (open  squares.  Figure  1).  The  survival 
of  transgenic  mice  of  the  70-2  line  (closed  circles. 
Figure  1)  appeared  to  be  slightly  reduced  rela- 
tive to  littermate  controls  (open  circles.  Figure 
1).  Monitoring  more  animals  will  be  required  to 
determine  if  the  reduced  survival  of  SPC-DNp53 
transgenic  mice  in  the  70-2  line  is  significant. 
Transgenic  mice  from  the  70-2  transgenic  line 
express  dominant  negative  human  p53  at  higher 
levels  in  the  lung  and  in  a more  widespread 
pattern  in  the  lung  epithelium  than  transgenic 
animals  in  the  70-3  transgenic  line.8  However, 
another  cohort  of  transgenic  mice  in  the  70-2  line 


monitored  for  long-term  survival  after  a brief 
exposure  to  asbestos  did  not  display  reduced 
survival  (see  below). 

The  mice  were  weighed  during  the  moni- 
toring period  as  a means  of  assessing  the 
animal's  health.  Most  of  the  animals  in  both 
transgenic  lines  maintained  or  gained  weight. 
Only  two  mice  in  the  70-2  line  lost  weight  (13%) 
and  both  of  the  animals  were  nontransgenic 
(Table  1A).  Six  of  the  transgenic  mice  in  the  70-3 
line  lost  weight  (27%),  while  three  of  the 
nontransgenic  littermates  (20%)  lost  weight 
(Table  IB).  Although  more  mice  in  the  70-3  line 
lost  weight,  the  survival  of  mice  in  the  70-3  line 
was  similar  to  that  of  the  70-2  line  (Figure  1). 


Table  1A. 

Observations  of  individual  SPC-DNp53  transgenic  mice  and  nontransgenic  littermates  in  line  70-2. 

Animal 

Genotype 

Sex 

Age 

Comments  and  Gross  Findings 

Cl 

- 

M 

78 

Weight  loss  approximately  1% 

C2 

+ 

M 

78 

No  abnormal  findings 

C3 

+ 

M 

78 

No  abnormal  findings 

C4 

- 

F 

78 

No  abnormal  findings 

C5 

- 

F 

78 

No  abnormal  findings 

C6 

- 

F 

78 

No  abnormal  findings 

C7 

+ 

F 

31 

No  abnormal  findings 

C8 

- 

F 

28 

Accidental  death,  no  abnormal  findings 

C9 

+ 

F 

31 

Accidental  death,  no  abnormal  findings 

CIO 

+ 

F 

31 

No  abnormal  findings 

Cll 

- 

F 

79 

No  abnormal  findings 

C12 

- 

F 

79 

No  abnormal  findings 

C13 

+ 

F 

78 

No  abnormal  findings 

C14 

+ 

M 

80 

No  abnormal  findings 

C15 

+ 

M 

79 

No  abnormal  findings 

C16 

- 

M 

78 

No  abnormal  findings 

C17 

- 

M 

79 

No  abnormal  findings 

C18 

- 

M 

79 

No  abnormal  findings 

C19 

+ 

F 

79 

Suspicious  lung  lesions,  tumor? 

C20 

- 

F 

41 

No  abnormal  findings 

C21 

+ 

M 

76 

No  abnormal  findings 

C22 

+ 

M 

78 

No  abnormal  findings 

C50 

+ 

M 

72 

White  fluid  in  chest  cavity,  enlarged  area  in  the  colon 

C51 

+ 

M 

78 

No  abnormal  findings 

C52 

- 

M 

78 

No  abnormal  findings 

C53 

- 

M 

78 

Weight  loss  approximately  7% 

C54 

- 

F 

78 

No  abnormal  findings 

C55 

- 

F 

71 

No  abnormal  findings 

C56 

+ 

F 

78 

No  abnormal  findings 

C57 

+ 

F 

78 

No  abnormal  findings 

The  table  shows  the  mouse 

designation;  if  the  animal 

was  transgenic  (+)  or  nontransgenic  (-);  the  sex,  male  (M)  or 

female  (F);  the  age  (in  weeks)  at  time  of  death  or  sacrifice;  and  any  observations  relating  to  the  animal's  health.  Mice 

appearing 

moribund  were 

sacrificed.  All  the  animals 

were  sacrificed  at  18  months  regardless  of  apparent  health. 

184  J La  State  Med  Soc  VOL  152  April  2000 


Cancer  in  Louisiana 


Table  IB. 

Observations  of  individual  SPC-DNp53  transgenic  mice  and  nontransgenic  littermates  in  line  70-3. 

Animal 

Genotype 

Sex 

Age 

Comments  and  Gross  Findings 

. C23 

- 

M 

29 

Accidental  death,  no  abnormal  findings 

C24 

+ 

M 

29 

Accidental  death,  no  abnormal  findings 

C25 

- 

M 

31 

Accidental  death,  no  abnormal  findings 

C27 

+ 

F 

78 

Weight  loss  >10%,  no  abnormal  findings 

C28 

+ 

F 

78 

No  abnormal  findings 

C30 

- 

F 

78 

No  abnormal  findings 

C31 

+ 

F 

56 

Weight  loss  >35%,  hair  loss  around  eyes  and  neck,  lungs  enlarged,  blood  in  gut 

C32 

- 

F 

78 

No  abnormal  findings 

C33 

- 

F 

78 

Approximately  3%  weight  loss 

C34 

- 

F 

78 

Approximately  4%  weight  loss 

C35 

+ 

M 

25 

Accidental  death,  no  abnormal  findings 

C36 

+ 

M 

78 

Weight  loss  >6%, 

C37 

- 

M 

78 

No  abnormal  findings 

C38 

+ 

F 

78 

Lymphoma?  multiple  nodules  in  small  intestine,  liver  and  salivary  gland 

C39 

+ 

F 

78 

No  abnormal  findings 

C40 

+ 

F 

78 

No  abnormal  findings 

C41 

+ 

F 

78 

No  abnormal  findings 

C42 

+ 

F 

78 

Weight  loss  >8% 

C43 

- 

F 

78 

No  abnormal  findings 

C44 

- 

F 

78 

No  abnormal  findings 

C45 

+ 

M 

78 

Weight  loss  approximately  19%,  suspicious  lesions  on  the  lung 

C46 

- 

M 

78 

No  abnormal  findings 

C47 

+ 

F 

132 

No  abnormal  findings 

C48 

+ 

F 

78 

No  abnormal  findings 

C60 

- 

F 

78 

No  abnormal  findings 

C61 

- 

F 

78 

Weight  loss  approximately  15% 

C62 

+ 

F 

78 

No  abnormal  findings 

C63 

+ 

F 

78 

No  abnormal  findings 

C64 

+ 

M 

79 

No  abnormal  findings 

C65 

+ 

M 

79 

No  abnormal  findings 

C66 

+ 

M 

79 

Weight  loss  approximately  1 9% 

C67 

+ 

M 

79 

No  abnormal  findings 

C68 

- 

M 

79 

No  abnormal  findings 

C69 

- 

M 

79 

No  abnormal  findings 

C70 

+ 

F 

79 

No  abnormal  findings 

C71 

+ 

F 

79 

No  abnormal  findings 

C72 

- 

F 

59 

Abdomen  enlarged 

Same  as  Table  IB,  except  the  mice 

are  from  the  70-3  transgenic  line. 

J La  State  Med  Soc  VOL  152  April  2000  185 


Cancer  in  Louisiana 


Thus,  the  health  of  the  mice  as  assessed  by 
weight  loss  was  not  affected  by  the  transgene. 

All  of  the  mice  were  evaluated  grossly  for 
abnormalities  upon  death  or  sacrifice  and  the 
gross  findings  are  presented  in  Tables  1A  and 
IB.  The  lungs  of  each  animal  were  inflated  by 
intratracheal  perfusion  of  fixative,  and  then  the 
lungs  were  removed  from  the  chest  cavity  and 
stored  in  fixative  overnight.  The  lobes  of  the 
fixed  lung  tissue  were  separated  and  inspected 
for  abnormalities  before  being  placed  into  cas- 
settes for  paraffin  embedding.  The  lungs  of  most 
mice  appeared  unremarkable,  but  a mass  ap- 
peared on  the  lungs  of  a transgenic  mouse  (C19 
and  C45)  from  each  line.  Whether  or  not  the  le- 
sions are  tumors  that  are  related  to  expression 
of  the  transgene  will  require  histological  and 
immunohistochemical  evaluation.  Moreover, 
lung  sections  will  be  prepared  from  the  paraffin 
embedded  lung  tissue  from  all  of  the  mice  and 
examined  microscopically  for  lesions. 

Individuals  exposed  occupationally  to  asbes- 
tos display  an  elevated  incidence  of  lung  can- 


cer.13 To  determine  if  the  carcinogenic  effects  of 
inhaled  asbestos  are  amplified  in  the  presence 
of  dominant  negative  p53,  we  exposed  SPC- 
DNp53  transgenic  mice  and  nontransgenic  lit- 
termates  to  an  aerosol  of  asbestos  for  5 hours. 
The  long-term  survival  of  the  asbestos-exposed 
mice  from  both  transgenic  lines  is  shown  in  Fig- 
ure 2 and  Table  2.  The  survival  of  both  transgenic 
and  nontransgenic  mice  in  the  70-2  line  (circles) 
appeared  to  be  reduced  relative  to  the  survival 
of  mice  in  the  70-3  line  (squares.  Figure  2).  The 
survival  of  transgenic  mice  and  nontransgenic 
littermates  of  both  lines  was  not  significantly 
different  (Figure  2).  A number  of  the  asbestos- 
exposed  transgenic  mice  and  nontransgenic  lit- 
termates survived  for  more  than  100  weeks  and 
some  continue  to  survive  for  longer  than  100 
weeks  (Table  2).  These  ongoing  observations 
suggest  that  a single  brief  exposure  to  asbestos 
did  not  significantly  reduce  the  long-term  sur- 
vival of  the  SPC-DNp53  transgenic  relative  to 
that  of  the  simultaneously  exposed  non- 
transgenic littermates.  Whether  or  not  the  asbes- 


</> 

k. 

o 

> 

> 

k. 

3 


0-19  20-30  31-40  41-50  51-60  61-70  71-80  81-90  91-100 


Weeks 

Figure  2.  Same  as  Figure  1,  except  the  mice  in  each  group  were  exposed  one  time  for  5 hours  to  an  aerosol  of 
asbestos  at  12.5  mg/ m3. 


186  J La  State  Med  Soc  VOL  152  April  2000 


Cancer  in  Louisiana 


Table  2.  Asbestos-exposed  SPC-DNp53  transgenic 
greater  than  100  weeks  (as  of  11/99). 

mice  and  nontransgenic  littermates  surviving 

Line 

Genotype 

Status 

# of 

Age  (weeks) 

animals 

102 

103 

105 

106 

109 

110 

111 

70-2 

NT 

deceased 

1 

1 

survivors 

3 

1 

2 

70-2 

T 

deceased 

2 

1 

1 

survivors 

2 

2 

70-3 

NT 

deceased 

2 

1 

1 

survivors 

9 

5 

1 

3 

70-3 

T 

deceased 

2 

1 

1 

survivors 

5 

2 

1 

2 

The  table  shows  the  number  of  transgenic  (T)  and  nontransgenic  (NT)  mice  in  each  line  (70-2  or  70-3) 
surviving  longer  than  100  weeks.  The  number  of  surviving  mice  of  each  type  and  their  current  ages 
are  indicated.  The  number  of  mice  of  each  type  that  died  after  100  weeks  and  their  age  upon  death 
are  also  indicated. 

tos-exposed  transgenic  mice  manifest  an  increase 
in  neoplastic  lesions  of  the  lung  will  require 
analyses  of  lung  tissue  from  each  mouse. 

DISCUSSION 

We  describe  here  a mouse  model  relevant  to  hu- 
man lung  adenocarcinoma  with  mutant  p53  ex- 
pression. The  survival  analyses  shown  in  Figures 
1 and  2 suggest  that  the  incidence  of  lung  tumor 
development  in  the  transgenic  mice,  if  it  occurs, 
is  very  low.  In  mouse  models  similar  to  the  one 
described  here,  p53  promoter-directed  expres- 
sion of  a dominant  negative  form  of  p53 
(p53vall35,  alanine  to  valine  change  at  amino 
acid  135)  promotes  tumorigenesis  in  the  lung 
with  a delayed  onset  (approximately  1 year)  and 
an  incidence  of  approximately  10%.67  The  high 
incidence  of  lymphoma  development  in  these 
p53vall35  mice  diminishes  their  utility  as  a lung 
cancer  model.6  7 A higher  lung  cancer  incidence, 
approximately  50%,  occurs  if  the  p53vall35 
transgene  is  expressed  in  the  lung  cancer-prone 
FVB/N  mouse  strain  (background  lung  cancer 
incidence  of  28%  in  nontransgenic  mice)  and  the 
rate  of  tumor  development  remains  rather  slow.14 
In  an  attempt  to  improve  upon  these  existing 
models  for  lung  cancer,  we  expressed  a highly 
oncogenic  dominant  negative  form  of  human  p53 
specifically  in  the  lung  with  the  human  surfac- 
tant protein  C promoter.  This  restricted  pattern 


of  expression  of  the  tumor  promoting  transgene 
in  mice  confines  tumorigenesis  to  the  lung.  Al- 
though these  SPC-DNp53  transgenic  mice  ex- 
press large  amounts  of  mutant  p53  specifically 
in  the  lung,  the  unaffected  survival  of  the 
transgenic  animals  suggests  a low  incidence,  if 
any,  of  lung  cancer.  The  SPC-DNp53  transgenic 
mice  possess  a partial  genetic  background  of 
C57BL  / 6,  a lung  cancer-resistant  strain1,  which 
might  account  for  the  less  than  expected  inci- 
dence of  lung  tumors  in  the  transgenic  animals 
and  a low  background  of  spontaneously  occur- 
ring lung  tumors  in  the  nontransgenic  litter- 
mates. 

Despite  the  frequent  occurrence  of  p53  mu- 
tations in  human  lung  cancers,3  p53  mutations 
are  relatively  rare  in  mouse  models  of  chemi- 
cally-induced lung  tumors.15  The  transgenic  ap- 
proach provides  a means  of  modeling  human 
lung  cancer  in  mice.  Tumors  develop  rapidly  in 
mice  that  are  homozygous  for  a deletion  of  the 
p53  gene  with  a rare  incidence  of  lung  tumors.7 
p53  Heterozygous  mice  develop  tumors  at  a 
slower  rate  and  expression  of  a dominant  nega- 
tive p53  transgene  in  p53  heterozygous  mice  in- 
creases the  incidence  of  lung  tumors,  but  other 
tumor  types  continue  to  develop/  In  a similar 
approach,  breeding  the  SPC-DNp53  transgenic 
animals  described  here  with  the  p53  heterozy- 
gous mice  might  produce  lung  neoplasias  with 
a high  incidence. 


J La  State  Med  Soc  VOL  152  April  2000  187 


Cancer  in  Louisiana 


A number  of  strains  of  transgenic  mice  have 
been  produced  that  develop  lung  adenocarci- 
nomas. Transgenic  mice  that  express  viral 
oncoproteins  from  a variety  of  promoters  that 
target  lung  epithelial  cells  succumb  to  pulmo- 
nary adenocarcinomas  rapidly.1619  However, 
tumors  produced  by  the  viral  oncogene  do  not 
accurately  model  the  human  disease.  Mice  har- 
boring a transgene  with  the  albumin  enhancer/ 
promoter  directing  expression  of  mutated  on- 
cogenic H-ras  (AVo-ras)  generally  develop  liver 
abnormalities,  but  various  lines  of  AVo-ras 
transgenic  mice  develop  adenomatous  lung 
tumors  with  variable  rates.20  In  humans,  the  K- 
ras  gene  is  predominantly  expressed  in  the  lung 
epithelium  and  oncogenic  mutations  in  K -ras 
frequently  occur  in  human  lung  cancers.1 

The  absence  of  disease  with  a rapid  onset 
in  the  untreated  SPC-DNp53  transgenic  mice 
provides  the  opportunity  to  assess  toxic  sub- 
stances for  tumor  promoting  effects.  Occupa- 
tional exposure  to  asbestos  increases  the  inci- 
dence of  lung  cancer  without  affecting  the  type 
of  lung  tumor.1321  Inhaled  asbestos  injures  the 
lung  epithelial  cells  that  express  dominant  nega- 
tive p53  in  the  SPC-DNp53  transgenic  mice.22 
Therefore,  we  predicted  that  the  tumor  promot- 
ing potential  of  inhaled  asbestos  would  be  am- 
plified in  mice  with  genetic  instability  in  the 
lung  epithelium  due  to  compromised  p53  func- 
tion in  these  cells.  Although  the  analyses  are 
ongoing,  the  asbestos  exposure  did  not  specifi- 
cally reduce  the  survival  of  the  SPC-DNp53 
transgenic  mice  relative  to  the  simultaneously 
exposed  littermate  controls  (Figure  2 and  Table 
2).  Consequently,  a dramatic  increase  in  lung 
tumors  in  the  asbestos-exposed  transgenic  mice 
is  unexpected.  The  brief  asbestos  exposure  em- 
ployed here  is  sufficient  to  elicit  a rapid 
fibrogenic  response  that  subsides  with  time 
post-exposure.22  Multiple  exposures  to  asbes- 
tos produce  prolonged  fibrogenesis  leading  to 
fibrotic  lesions  that  persist  for  at  least  6 
months.23  This  multiple  exposure  regimen  and 
consequent  development  of  fibrotic  lung  dis- 
ease may  be  necessary  to  observe  an  elevated 
lung  cancer  incidence  in  the  SPC-DNp53 


transgenic  mice  similar  to  that  in  humans  with 
asbestosis.22 

ACKNOWLEDGMENTS 

This  work  was  supported  by  research  grants 
from  the  Louisiana  Cancer  and  Lung  Trust  Fund 
Board  and  the  Tulane  / Xavier  Center  for  Bioen- 
vironmental  Research  to  Gilbert  F Morris,  PhD 
and  the  Wetmore  Foundation  to  Mitchell  Fried- 
man, MD.  Anne  B Nelson,  PhD  received  match- 
ing support  from  the  Tulane  Cancer  Center. 

REFERENCES 

1 . Tu veson  DA,  J acks  T.  Modeling  human  lung  cancer 
in  mice:  similarities  and  shortcomings.  Oncogene 
1999;18:5318-5324. 

2.  Chen  VW,  Andrews  PA,  Wu  XC,  et  al.  Cancer 
incidence  in  the  industrial  corridor:  an  update.  J La 
State  Med  Soc  1998;  150:158-167. 

3.  Greenblatt  MS,  Bennett  WP,  Hollstein  M,  et  al. 
Mutations  in  the  p53  tumor  suppressor  gene:  clues 
to  cancer  etiology  and  molecular  pathogenesis. 
Cancer  Res,  1994;  54:4855-4878. 

4.  Denissenko  MF,  Pao  A,  Tang  M-S,  et  al.  Preferential 
formation  of  benzo [a] pyrene  adducts  at  lung  cancer 
mutational  hotspots  in  p53.  Science  1996;274:430- 
432. 

5.  Zambetti  GP,  Levine  AJ.  A comparison  of  the 
biological  activities  of  wild-type  and  mutant  p53. 
FASEB  J 1993;7:855-865. 

6.  Lavigueur  A,  Maltby  V,  Mock  D,  et  al.  High 
incidence  of  lung,  bone,  and  lymphoid  tumors  in 
transgenic  mice  overexpressing  mutant  alleles  of 
the  p53  oncogene.  Mol  Cell  Biol  1989;9:3982-3991. 

7.  Harvey  M,  Vogel  H,  Morris  D,  et  al.  A mutant  p53 
transgene  accelerates  tumor  development  in 
heterozygous  but  not  nullizygous  p53-deficient 
mice.  Nat  Genet  1995;9:305-311. 

8.  Morris  GF,  Hoyle  GW,  Athas  GB,  et  al.  Lung- 
specific  expression  in  mice  of  a dominant  negative 
mutant  form  of  the  p53  tumor  suppressor  protein. 
J La  State  Med  Soc  1998;150:179-185. 

9.  Mishra  A,  Liu  JY,  Brody  AR,  et  al.  Inhaled  asbestos 
fibers  induce  p53  expression  in  the  rat  lung.  Ain  J 
Respir  Cell  Mol  Biol  1997;16:479-485. 

10.  Sambrook  J,  Fritsch  EF,  Maniatis  T.  Molecular 
Cloning,  A Laboratory  Manual,  2nd  edition.  Cold 
Spring  Harbor,  NY:  Cold  Spring  Harbor  Press;  1989. 


188  J La  State  Med  Soc  VOL  152  April  2000 


Cancer  in  Louisiana 


11.  Hainaut  P,  Soussi  T,  Shomer  B,  et  al.  Database  of 
p53  somatic  mutations  in  human  tumors  and  cell 
lines:  updated  compilation  and  future  prospects. 
Nucleic  Acids  Res  1997;25:151-157. 

12.  Dittmer  D,  Pati  S,  Zambetti  G,  et  al.  Gain  of 
function  mutations  in  p53.  Nat  Genet  1993;4:42-46. 

13.  Stayner  LT,  Dankovic  DA,  Lemen  RA. 
Occupational  exposure  to  chrysotile  asbestos  and 
cancer  risk:  a review  of  the  amphibole  hypothesis. 
Am  J Public  Health  1996;86:179-186. 

14.  Shafarenko  M,  Mahler  J,  Cochran  C,  et  al.  Similar 
incidence  of  K -ras  mutations  in  lung  carcinomas 
of  FVB/N  mice  and  FVB/N  mice  carrying  a 
mutant  p53  transgene.  Carcinogenesis  1997;18:1423- 
1426. 

15.  Dragani  TA,  Manenti  G,  Pierotti  MA.  Genetics  of 
murine  lung  tumors.  Adv  Cancer  Res  1995;67:83- 
112. 

16.  Wikenheiser  KA,  Clark  JC,  Linnoila  RI,  et  al.  Simian 
virus  40  large  T antigen  directed  transcriptional 
elements  of  the  human  surfactant  protein  C gene 
produces  pulmonary  adenocarcinomas  in  trans- 
genic mice.  Cancer  Res  1992;52:5342-5352. 

17.  Magdaleno  SM,  Wang  G,  Mireles  VL,  et  al.  Cyclin- 
dependent  kinase  inhibitor  expression  in 
pulmonary  Clara  cells  transformed  with  SV40  large 
T antigen  transgenic  mice.  Cell  Growth  Differ 
1997;8:145-155. 

18.  Sandmoller  A,  Halter  R,  Suske  G,  et  al.  A transgenic 
mouse  model  for  lung  adenocarcinoma.  Cell 
Growth  Differ  1995;6:97-103. 

19.  Lebel  M,  Webster  M,  Muller  WJ,  et  al.  Transgenic 
mice  bearing  the  polyomavirus  large  T antigen 
directed  by  2.1  kb  of  the  keratin  19  promoter 
develop  bronchiolar  papillary  tumors  with 
progression  to  lung  adenocarcinomas.  Cell  Growth 
Differ  1995;6:1591-1600. 

20.  Maronpot  RR,  Palmiter  RD,  Brinster  RL,  et  al. 
Pulmonary  carcinogenesis  in  transgenic  mice.  Ex 
Lung  Res  1991;17:305-320. 

21.  de  Klerk  NH,  Musk  AW,  Eccles  JL,  et  al.  Exposure 
to  crocidolite  and  the  incidence  of  different 
histological  types  of  lung  cancer.  Occup  Environ 
Med  1996;53:157-159. 

22.  Morris  GF,  Brody,  AR.  Molecular  mechanisms  of 
particle-induced  lung  disease.  In  Rom  WN  (editor). 
Environmental  and  Occupational  Medicine,  3rd 
edition.  Philadelphia,  Pa:  Lippincott-Raven; 
1998:305-333. 

23.  Coin  PC,  Osornio-Vargas  A,  Moore  L,  et  al. 
Pulmonary  fibrogenesis  after  three  consecutive 
inhalation  exposures  to  chrysotile  asbestos.  Am  J 
Respir  Crit  Care  Med  1996;154:1511-1519. 


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Cancer  in  Louisiana 


Selenium:  Increasing  Evidence  of  Effective 
Cancer  Chemoprevention 

Oliver  Sartor,  MD 


Chemoprevention  of  cancer  has  intrigued  researchers  over  the  past  several  decades.  In 
recent  years,  positive  results  have  been  reported  in  a number  of  clinical  trials.  In  this  brief 
review,  selenium  supplementation  is  reviewed  with  emphasis  on  data  from  prospective, 
randomized,  placebo-controlled  trials.  One  such  study  has  been  completed  in  the  United 
States.  In  this  study,  performed  by  the  Nutritional  Prevention  of  Cancer  Study  Group, 
individuals  randomized  to  selenium  supplementation  had  a statistically  significant 
reduction  in  the  incidence  of  non-skin  cancers  and  cancer-related  deaths.  Reductions  in 
the  incidence  of  lung,  prostate,  and  colorectal  cancers  were  specifically  noted.  Benefit 
appeared  to  be  restricted  to  individuals  with  lower  (<121  ng/mL)  baseline  selenium  levels. 
Additional  studies  have  been  conducted  in  China;  two  of  these  trials  demonstrated  a 
statistically  significant  reduction  in  hepatoma  in  individuals  infected  with  the  hepatitis  B 
virus.  Additional  prospective  trials  using  selenium  supplementation  are  planned  in  the 
near  future. 


After  years  of  efforts  directed  toward  the 
development  of  effective  cancer 
chemopreventive  agents,  researchers 
heralded  two  recent  drug  approvals  by  the  Food 
and  Drug  Administration  (FDA).  Tamoxifen 
gained  FDA  approval,  with  considerable  pub- 
licity, for  studies  demonstrating  a reduction  in 
the  incidence  of  breast  cancer  for  women  at  high 
risk  of  this  disease.  Getting  far  less  attention  was 
the  FDA  approval  of  a Celebrex,  a COX-2  inhibi- 
tor, as  an  adjunct  to  the  usual  care  of  patients 
with  familial  adenomatous  polyposis.  This  ge- 
netic disease  is  associated  with  colorectal  can- 
cer by  age  50  in  virtually  all  untreated  patients. 
Additional  efforts  have  been  underway  in  the 
chemoprevention  field  for  years.  Notable  fail- 


ures include  trials  involving  beta-carotene 
supplementation  for  lung  cancer  prevention.12 
In  this  brief  overview,  emphasis  will  be  placed 
on  prospective,  randomized,  placebo-controlled 
trials  using  selenium  supplementation. 

Trials  from  the  Nutritional  Prevention  of  Can- 
cer Study  Group 

In  a prospective,  randomized,  multi-center  trial, 
Larry  Clark  and  colleagues3  tested  the  hypoth- 
esis that  dietary  selenium  supplementation  may 
reduce  the  recurrence  rate  of  basal  and  squa- 
mous cell  carcinomas  of  the  skin.  In  this  inter- 
vention trial,  1312  patients  with  a history  of  basal 
or  squamous  carcinomas  of  the  skin  were  ran- 
domized in  a double-blind  fashion  to  selenium 


190  J La  State  Med  Soc  VOL  152  April  2000 


Cancer  in  Louisiana 


supplementation  or  a placebo.  Patients  in  the  se- 
lenium supplementation  group  received  200  mi- 
crograms per  day  of  a selenium  enriched  yeast 
preparation.  Patients  in  the  placebo  group  re- 
ceived an  identical  appearing  tablet  of  yeast  ex- 
tract. Patients  were  recruited  from  1983  to  1990 
and  were  followed  for  an  average  of  6.4  years. 
There  was  a total  of  8,271  person-years  of  data. 
All  patient-reported  illnesses  were  confirmed  us- 
ing appropriate  consultation  with  the  patient's 
medical  care  providers  and  a review  of  medical 
records.  Selected  results  are  shown  below  in  the 
Table. 

The  study  by  Clark  and  colleagues  did  not 
demonstrate  a significantly  reduced  incidence 
of  recurrent  basal  or  squamous  cell  carcinomas 
of  the  skin.  The  selenium  treatment  arm,  how- 
ever, had  a statistically  significant  reduction  in 
total  non-skin  cancer  incidence  and  cancer-spe- 
cific mortality.  The  selenium  group  had  a 37% 
lower  risk  of  non-skin  malignancies  (P  = .001) 
and  a 50%  lower  risk  of  dying  from  cancer  (P  = 
.002).  There  was  also  a statistically  significant 
reduction  in  the  risk  of  three  major  adult  can- 
cers. In  the  selenium  group  there  was  a relative 
risk  for  lung  cancer  of  0.54  (P  = .04),  a relative 
risk  for  colorectal  cancer  of  0.42  (P  = .03),  and  a 
relative  risk  for  prostate  cancer  of  0.37  (P  = .002). 
In  addition  there  was  a relative  risk  of  lung  can- 
cer-specific-mortality of  0.47  (P  = 0.03)  in  the 
selenium  arm.  We  emphasize  that  both  the  lung 
cancer  incidence  and  mortality  rates  were  re- 
duced by  approximately  50%  in  patients  ran- 


domized to  receive  selenium  supplementation. 

These  effects  were  consistent  over  the  period 
of  time  studied  with  increased  effect  after  the 
first  year  (as  expected  for  a chemopreventive 
agent).  Furthermore  these  findings  were  present 
across  a broad  spectrum  of  the  clinics  accruing 
patients  to  the  trial.  No  cases  of  selenium  toxic- 
ity were  documented  in  this  study,  unequivo- 
cally demonstrating  that  a dose  of  200  micro- 
gram per  day  was  safe  in  this  population. 

Because  of  the  surprising  reductions  in  total 
cancer  mortality  and  total  cancer  incidence  in 
the  selenium  intervention  group,  after  review  by 
the  Safety  Monitoring  and  Advisory  Commit- 
tee, the  study  was  prematurely  closed  and  au- 
dited by  staff  from  the  National  Cancer  Insti- 
tute. The  audit  confirmed  the  quality  of  the  data. 

A careful  analysis  of  the  trial  suggested  that 
selenium  supplementation  was  effective  in  can- 
cer prevention  only  in  individuals  with  selenium 
blood  levels  in  the  lower  two  tertiles  (Combs, 
Clark,  and  Turnbull,  personal  communication). 
The  data  suggested  that  protective  effects  of  se- 
lenium are  most  evident  when  baseline  blood 
selenium  levels  are  less  than  121  ng/  mL. 

This  provocative  study,  utilizing  a series  of 
secondary  endpoints,  demonstrated  a reduced 
incidence  of  non-skin  malignancies  and  a re- 
duced mortality  from  cancer.  Decreases  were 
noted  in  the  incidence  of  three  major  adult  ma- 
lignancies including  lung,  prostate,  and  colon. 
These  cancers  rank  among  the  top  four  causes 
of  malignancy-induced  death  in  the  United 


Table.  Selected  results  in  the  selenium  versus  placebo  study  conducted  by  Clark  and 
colleagues.3 


Placebo 

Selenium 

Relative  Risk 

P value 

Cases  of  Lung  Cancer 

31  cases 

17  cases 

RR  = 0.54 

.04 

Lung  Cancer  Deaths 

25  deaths 

12  deaths 

RR  = 0.47 

.03 

Total  (Non-Skin)  Cancers 

119  cases 

77  cases 

RR  = 0.63 

.001 

Total  Cancer  Deaths 

57  deaths 

29  deaths 

RR  = 0.50 

.002 

J La  State  Med  Soc  VOL  152  April  2000  191 


Cancer  in  Louisiana 


States.  The  necessity  of  confirming  this  trial  with 
additional  studies  is  acknowledged  by  both  the 
primary  investigators  as  well  as  by  other  inves- 
tigators in  the  field.  There  is  a clear  need,  in  par- 
ticular, to  evaluate  the  effects  on  lung  cancer  in 
a larger  trial,  as  this  represents  the  single  largest 
cause  of  cancer-specific  mortality  in  the  United 
States  today. 

Randomized  selenium  trials  in  Linxian,  China 

Linxian  is  a community  in  the  Henan  Province 
in  the  north  central  region  of  China  with  one  of 
the  highest  cancer  rates  in  the  world.  An  extraor- 
dinary risk  of  esophagus  and  gastric  cancer  is 
detected  in  this  region,  with  a lifetime  risk 
thought  to  exceed  25%.  The  reason  behind  this 
extraordinary  high  risk  of  cancer  is  unclear, 
though  dietary  factors  are  potentially  implicated. 

Two  randomized  trials  have  been  conducted 
in  the  Linxian  area  using  multi-vitamin  or  min- 
eral supplementation;  one  of  these  trials  utilized 
selenium  enriched  yeast  as  part  of  the  experi- 
mental intervention.  In  this  particular  trial,  of- 
ten referred  to  as  the  Linxian  General  Popula- 
tion Trial,  29,584  persons  were  randomized  be- 
ginning in  1986. 4 Tablets  were  distributed 
monthly  and  compliance  assessed  by  pill  counts 
as  well  as  assay  of  various  nutrients  in  the  se- 
rum of  randomly  selected  participants.  Four  ran- 
domized groups  were  evaluated.  These  groups 
included  (1)  retinol  plus  zinc,  (2)  riboflavin  plus 
niacin,  (3)  ascorbic  acid  plus  molybdenum  and 
(4)  a combination  of  beta-carotene  plus  selenium 
plus  alpha-tocopherol.  The  selenium  dose  of  50- 
micrograms  was  supplied  as  a selenized  yeast 
preparation.  The  mean  duration  of  the  selenium 
intervention  was  5.25  years. 

No  significant  effects  on  cancer-specific  mor- 
tality were  associated  with  the  non-selenium 
containing  regimens.  However,  in  the  group 
treated  with  selenium  at  50  micrograms  per  day 
in  combination  with  alpha-tocopherol  (30  milli- 
grams per  day)  and  beta-carotene  (15  milligrams 
per  day),  a statistically  significant  reduction  in 
total  mortality  and  cancer-specific  mortality  was 
observed  (9%  and  13%,  respectively).  The  reduc- 
tion was  apparent  within  2 years  of  supplemen- 


tation. Lung  cancer  was  reduced  by  approxi- 
mately 50%  in  individuals  receiving  beta-caro- 
tene, alpha-tocopherol,  and  selenium;  however, 
only  31  deaths  were  reported  for  lung  cancer. 
Statistical  significance  for  lung  cancer  was  not 
reached  because  of  the  small  number  of  these 
patients  in  the  study. 

A second  placebo-controlled  randomized 
Linxian  trial  used  a cohort  of  individuals  with 
esophageal  dysplasia  receiving  either  placebo  or 
two  multivitamin  with  mineral  tablets  and  a 
beta-carotene  tablet.  No  differences  were  seen 
in  this  trial.5  Sodium  selenate  (50  meg  daily),  not 
a yeast  preparation,  was  used  in  this  study. 

The  use  of  beta-carotene  in  this  trial  may  very 
well  have  increased  risk  of  lung  cancer.  Inter- 
vention with  beta-carotene  in  the  Finnish  smok- 
ers trial1  and  in  the  CARET  trial2  was  associated 
with  increased  lung  cancer  risk. 

Randomized  trials  in  Qidong,  China 

High  rates  of  hepatitis  B infection  and  hepatoma 
are  present  within  Qidong,  a county  within  the 
Jiangsu  region  of  China.  Prior  to  selenium  inter- 
vention trials,  epidemiologic  data  had  revealed 
inverse  associations  between  selenium  levels  in 
blood  and  liver  cancer  incidence  in  this  region.6 
Interestingly  in  this  region,  high  rates  of  pre- 
malignant  lesions  had  been  noted  in  domestic 
brown  ducks  because  of  aflatoxin  contaminated 
feed.  With  selenium  supplementation,  Qidong 
ducks  were  noted  to  have  a decreased  incidence 
of  preneoplastic  liver  foci.7 

In  a prospective  randomized  clinical  trial 
involving  226  hepatitis  B surface-antigen  posi- 
tive individuals,  200  micrograms  of  selenium 
supplementation  over  a 4-year  period  (in  the 
form  of  a selenized  yeast)  demonstrated  a sta- 
tistically significant  reduction  in  hepatoma  in- 
cidence as  compared  to  placebo.  There  were  no 
cases  of  hepatoma  in  the  selenium  supplemented 
group  as  compared  to  7 cases  within  the  placebo 
group.8 

In  an  additional  placebo-controlled  selenium 
intervention  study  involving  3,849  first  degree 
relatives  of  participants  with  hepatitis  B surface- 
antigen  positivity,  intervention  with  a selenium 


192  J La  State  Med  Soc  VOL  152  April  2000 


Cancer  in  Louisiana 


yeast  preparation  (again  200  micrograms  per 
day)  reduced  the  incidence  in  liver  cancer.  In  the 
followup  period,  the  incidence  of  liver  cancer 
was  219/100,000  in  the  selenium  supplementa- 
tion group  as  compared  to  553/100,000  in  the 
control  group.9 

In  an  intervention  trial  undertaken  among 
five  townships  with  a general  population  of 
130,471  individuals,  selenium  supplementation 
to  one  township  (20,847  persons)  via  a selenium 
supplemented  table  salt  reduced  liver  cancer 
incidence  by  35%  as  compared  to  the 
unsupplemented  population.8  Furthermore, 
upon  withdrawal  of  the  selenium  supplemented 
table  salt,  the  incidence  of  liver  cancer  increased 
to  a level  commensurate  with  the  control  popu- 
lation. 

Investigations  of  selenium  supplementation 
on  pre-malignant  lesions 

Several  additional  selenium  intervention  trials 
are  noteworthy.  A prospective,  randomized, 
double-blind,  placebo-controlled  trial  in  patients 
with  a prior  resection  of  adenomatous  polyps 
was  conducted  in  Italy.  Investigators  noted  a 44% 
decrease  in  the  incidence  of  new  polyps  in  a 
treatment  group  receiving  selenium  and  zinc  in 
combination  with  vitamins  C,  E,  and  A.10 

In  another  trial  utilizing  a combination  of 
interventional  agents  including  selenium,  smok- 
ers diagnosed  with  pre-malignant  oral  lesions 
were  treated  in  a placebo-controlled  trial  with  a 
combination  of  selenium,  vitamin  A.,  riboflavin, 
and  zinc.  A complete  remission  of  the  pre-ma- 
lignant lesions  was  noted  in  57%  of  the  treat- 
ment group  and  8%  of  the  placebo  group.11 
Though  these  data  clearly  include  intervention 
with  elements  other  than  selenium,  the  data 
again  are  consistent  with  the  hypothesis  that 
selenium  intervention  decreases  risk  of  pre-ma- 
lignant lesions. 

Putative  mechanisms  of  selenium  anti-car- 
cinogenic action 

Selenium  modulates  a variety  of  enzymatic  sys- 
tems implicated  in  pro-carcinogenic  processes.12 


Selenium  is  found  in  the  active  site  of  a number 
of  enzymes  as  the  modified  amino  acid 
selenocysteine.  This  moiety  is  essential  for  en- 
zymatic activity  of  thioredoxin  reductase,  at  least 
four  glutathione  peroxidases  (GSH-PXs),  three 
iodothyronine  deidonisases,  and  selenophos- 
phate  synthetase. 

Thioredoxin  reductase  has  been  implicated 
in  a variety  of  metabolic  actions  including  me- 
diation of  cell  death  induced  by  treatment  with 
certain  anti-cancer  treatments.13  The  GSFI-PXs 
exist  in  both  tissue-specific  and  ubiquitous 
forms  and  function  to  counteract  oxidative  at- 
tack by  the  reduction  of  peroxides.14  The  phos- 
pholipid hydroperoxide  glutathione  peroxidase 
is  one  of  the  critical  anti-oxidant  enzymes  pro- 
tecting membrane  lipids.  Selenophosphate  syn- 
thetase is  an  enzyme  required  to  insert 
selenocysteine  into  selenoproteins.  A number  of 
other  selenoproteins  (ie,  selenoproteins  P and 
W)  are  of  unknown  function. 

Interestingly,  additional  data  suggest  that 
selenium  may  have  a direct  anti-tumorigenic 
action  in  addition  to  its  effects  on  modulating 
enzymatic  activity.15  Some  studies  have  impli- 
cated methylated  selenium  compounds  (eg 
methylselenol,  dimethylselenide,  trimethylsele- 
nide)  as  potent  compounds  in  anti-carcinogenic 
action.  Data  also  suggest  that  selenium  treat- 
ment may  decrease  tumor  induced  angiogen- 
esis16 and  directly  elicit  apoptosis  in  cancer 
cells.17 

SUMMARY 

Selenium  has  demonstrated  evidence  of  cancer 
preventive  activity  in  a number  of  prospective, 
randomized,  placebo-controlled  trials.  Only  one 
of  these  studies  has  been  conducted  in  the 
United  States  and  the  relevance  of  the  Chinese 
studies  to  Americans  remains  unclear.  Prelimi- 
nary evidence  suggests  that  selenium  may  have 
cancer  prevention  effects  only  in  individuals 
having  selenium  levels  below  121  ng / mL.  Ad- 
ditional controlled  trials  using  selenium  are 
planned.  In  a study  funded  by  the  National  Can- 


J La  State  Med  Soc  VOL  152  April  2000  193 


Cancer  in  Louisiana 


cer  Institute,  selenium  and  Vitamin  E will  be 
assessed  for  chemopreventive  activity  in  pa- 
tients at  risk  for  prostate  cancer.  A variety  of 
other  proposals  are  currently  under  consider- 
ation for  funding  by  granting  agencies. 

REFERENCES 

1 . The  Alpha-Tocopherol,  Beta  Carotene  Cancer  Prevention 
Study  Group.  The  effect  of  vitamin  E and  beta  carotene 
on  the  incidence  of  lung  cancer  and  other  cancers  in 
male  smokers.  N Engl  J Med  1994;330:1029-1035. 

2.  Omenn  GS,  Goodman  GE,  Thornquist  MD,  et  al.  Risk 
factors  for  lung  cancer  and  for  intervention  effects  in 
CARET,  the  Beta-Carotene  and  Retinol  Efficacy  Trial.  / 
Natl  Cancer  Inst  1996;88:1550-1559. 

3.  Clark  LC,  Combs  GF,  Turnbull  BW,  et  al.  Effects  of 
selenium  supplementation  for  cancer  prevention  in 
patients  with  carcinoma  of  the  skin.  JAMA 
1996;276:1957-1963. 

4.  Blot  WJ,  Li  JY,  Taylor  PR,  et  al.  Nutrition  intervention 
trials  in  Linxian,  China:  supplementation  with  specific 
vitamin  / mineral  combinations,  cancer  incidence,  and 
disease-specific  mortality  in  the  general  population.  / 
Natl  Cancer  Inst  1993;85:1483-1492. 

5.  Li  JY,  Taylor  PR,  Li  B,  et  al.  Nutrition  intervention  trials 
in  Linxian,  China:  multiple  vitamin/mineral 
supplementation,  cancer  incidence,  and  disease-specific 
mortality  among  adults  with  esophageal  dysplasia.  / 
Natl  Cancer  Inst  1993;85:1492-1498. 

6.  Li  WG,  Gong  HM,  Xie  JR,  et  al.  Regional  distribution  of 
liver  cancer  and  its  relation  to  selenium  levels  in  Qidong 
County,  China.  Chung  Hua  Chung  Liu  Tsa  Chih  1986;8:262- 
264.  [Article  in  Chinese] 

7.  Yu  SY,  Chu  YJ,  Li  WG.  Selenium  chemoprevention  of 
liver  cancer  in  animals  and  possible  human  applications. 
Bio  Trace  Elem  Res  1988;15:231-241. 

8.  Yu  SY,  Zhu  YJ,  Li  WG.  Protective  role  of  selenium  against 
hepatitis  B virus  and  primary  liver  cancer  in  Qidong. 
Biol  Trace  Elem  Res  1997;56:117-124. 

9.  Li  WG.  Preliminary  observations  on  effect  of  selenium 
yeast  on  high  risk  populations  with  primary  liver  cancer. 
Chung  Hua  Yu  Fang  I Hsueh  Tsa  Chih  1992;26:268-271. 
[Article  in  Chinese] 

10.  Bonelli  L,  Conio  M,  Massa  P,  et  al.  Chemoprevention 
with  antioxidants  of  metachronous  adenomas  of  the 
large  bowel.  Cancer  Prevention  Control  1998;100:A351. 

11.  Krishnaswamy  K,  Prasad  MP,  Krishna  TP,  et  al.  A case 
study  of  nutrient  intervention  of  oral  precancerous 
lesions  in  India.  Eur  J Cancer  B Oral  Oncol  1995;31B:41- 
48. 

12.  Combs  GF,  Gray  WP.  Chemopreventive  agents: 
selenium.  Pharmacol  Ther  1998;79:179-192. 

13.  Hofmann  ER,  Boyanapalli  M,  Lindner  DJ,  et  al. 
Thioredoxin  reductase  mediates  cell  death  effects  of  the 
combination  of  beta  interferon  and  retinoic  acid.  Mol 
Cell  Biol  1998;18:6493-6504. 


14.  Holben  DH,  Smith  AM.  The  diverse  role  of  selenium 
within  selenoproteins:  a review.  J Am  Diet  Assoc  1999; 
99:836-843 

15.  Ip  C,  Hayes  C,  Budnick  RM,  et  al.  Chemical  form  of 
selenium,  critical  metabolites,  and  cancer  prevention. 
Cancer  Res  1991;51:595-600. 

16.  Jiang  C,  Jiang  W,  Ip  C,  et  al.  Selenium-induced  inhibition 
of  angiogenesis  in  mammary  cancer  at  chemopreventive 
levels  of  intake.  Mol  Carcinog  1999;26:213-225. 

17.  Stewart  MS,  Davis  RL,  Walsh  LP,  et  al.  Induction  of 
differentiation  and  apoptosis  by  sodium  selenite  in 
human  colonic  carcinoma  cells  (HT29).  Cancer  Lett 
1997;117:35-40. 


Dr  Sartor  is  the  Patricia  Powers  Strong  Professor  of 
Oncology  and  Director  of  the  Stanley  S.  Scott  Cancer 
Center  at  the  LSU  Health  Sciences  Center 
in  New  Orleans,  Louisiana. 


194  J La  State  Med  Soc  VOL  152  April  2000 


Cancer  in  Louisiana 


Incidence,  Trends,  and  Mortality  Rate  of 
Prostate  Cancer  in  Louisiana 

Mohammed  N.  Ahmed,  MD,  MPH;  Patricia  Andrews,  MPH;  Vivien  W.  Chen,  PhD; 
Xiao  Cheng  Wu,  MD,  MPH;  Catherine  N.  Correa,  MPH,  PhD; 

Beth  A.  Schmidt,  MSPH;  and  Elizabeth  T.H.  Fontham,  DrPH 


Carcinoma  of  the  prostate  is  the  most  commonly  diagnosed  cancer  and  the  second 
leading  cause  of  cancer  death  in  Louisiana  men.  Louisiana  Tumor  Registry  data  from 
1992  to  1996  were  used  to  calculate  prostate  cancer  incidence  rates  and  to  compare  with 
the  rates  from  the  National  Cancer  Institute's  Surveillance,  Epidemiology,  and  End 
Results  (SEER)  program.  Data  show  that  white  and  African-American  men  in  Louisiana 
have  significantly  lower  incidence  rates  than  SEER,  24%  lower  for  black  males  and  9% 
lower  for  white  males.  The  overall  incidence  has  increased  46%  since  1988,  in  large 
part  because  of  increased  screening.  The  incidence  rate  has  surpassed  that  for  lung 
cancer  in  Louisiana  since  1990,  a trend  also  observed  nationally.  The  mortality  rates 
from  prostate  cancer  approximate  the  national  average  for  all  races  in  Louisiana. 
Louisiana  men  have  lower  incidence  to  mortality  ratios,  which  indicate  poorer  survival 
than  their  national  counterparts.  Survival  is  particularly  worse  among  African 
Americans  and  warrants  culturally  sensitive  cancer  control  and  prevention  programs. 


Carcinoma  of  the  prostate  is  a significant 
public  health  problem  among  men  in 
Louisiana  and  throughout  the  United 
States.  With  increased  awareness  of  the  disease 
and  emphasis  on  early  detection,  its  diagnosis 
has  increased  dramatically  in  recent  years.  It  is 
estimated  that  in  1999  approximately  2,900  new 
cases  of  prostate  cancer  were  diagnosed,  which 
accounts  for  about  29%  of  all  male  cancers  in 
the  state.  The  disease  has  surpassed  lung  cancer 
as  the  most  commonly  diagnosed  cancer  in 
American  men.1  About  600  deaths  from  prostate 
cancer  occur  among  Louisiana  residents 
annually,  representing  12%  of  total  cancer  deaths 
and  the  second  leading  cause  of  cancer  deaths 
in  men,  after  lung  cancer.2 


This  article  compares  the  incidence  and 
mortality  rates  for  prostate  cancer  in  Louisiana 
with  national  rates,  1992-1996,  and  describes  the 
incidence  patterns  in  different  regions  in  the 
state.  Risk  factors  and  the  changes  in  incidence 
trends  are  discussed,  as  is  an  upcoming  study 
on  prostate  cancer  treatment  patterns  in 
Louisiana. 

METHODS 

Geographic  Area.  Based  on  historic  health 
districts,  Louisiana  is  divided  into  eight  regions: 
New  Orleans,  Baton  Rouge,  Southeast  Louisiana, 


J La  State  Med  Soc  VOL  152  April  2000  195 


Cancer  in  Louisiana 


Acadiana,  Southwest  Louisiana,  Central 
Louisiana,  Northwest  Louisiana,  and  Northeast 
Louisiana,  which  the  Louisiana  Tumor  Registry 
(LTR)  covers  for  compiling  and  editing  cancer 
information. 

Data  Collection.  Louisiana  law  requires  all 
licensed  health  care  providers  to  participate  in 
the  cancer  registration  program.  The  Louisiana 
Tumor  Registry  (LTR)  routinely  obtains  data  on 
newly  diagnosed  cancer  cases  from  all  hospitals, 
pathology  laboratories,  radiation  centers,  and 
ambulatory  surgical  facilities  in  the  state.  In 
addition,  physicians  who  diagnose  and  treat 
cases  solely  in  their  offices  are  to  report  these 
cases  to  the  Louisiana  Tumor  Registry  within  6 
months  of  diagnosis.  Patients  who  seek  medical 
care  outside  the  state  are  identified  through  data 
exchange  agreements  with  many  other  states  or 
through  subsequent  follow-up  care.  In  addition, 
death  certificates  of  Louisiana  residents  that 
contain  any  mention  of  cancer  are  linked  with 
the  LTR  database  to  ensure  that  cases  are  not 
missed. 

Quality  Control.  Data  are  edited  for 
accuracy  and  internal  consistency  in  both  the 
regional  and  the  central  registry  offices.  At  each 
level,  multiple  reports  of  the  same  cases, 
resulting  from  treatment  in  more  than  one 
facility,  are  reviewed  and  consolidated.  Staging 
information  for  prostate  cancer  underwent 
special  editing  procedures  as  part  of  a study  by 
the  North  American  Association  of  Central 
Cancer  Registries.3  In  calculating  incidence  and 
mortality  rates,  cases  are  always  assigned  to  their 
parish  of  residence,  rather  than  to  the  parish 
where  they  were  diagnosed. 

Case  Definition.  All  new  prostate  cancer 
cases  diagnosed  among  male  residents  of 
Louisiana  in  1992  to  1996  were  eligible.  Cancer 
sites  were  coded  by  both  primary  anatomic  site 
(C61.9)  and  morphology  using  the  International 
Classification  of  Disease  for  Oncology , 2nd  edition.4 

Computation  and  Comparison  of  Rates.  The 
National  Cancer  Institute's  Surveillance, 
Epidemiology,  and  End  Results  (SEER) 
incidence  rates  are  often  cited  as  the  "national" 
averages.  The  SEER  program  currently  includes 
11  geographic  areas  composed  of  the  states  of 

196  J La  State  Med  Soc  VOL  152  April  2000 


Connecticut,  Hawaii,  Iowa,  New  Mexico,  and 
Utah  and  the  metropolitan  areas  of  Atlanta, 
Georgia;  Detroit,  Michigan;  Los  Angeles,  San 
Francisco-Oakland  and  San  Jose-Monterey, 
California;  and  Seattle-Puget  Sound,  Wash- 
ington. The  SEER  areas  include  14.0%  of  the  total 
population,  but  they  are  reasonably  rep- 
resentative of  subsets  of  the  different  racial/ 
ethnic  groups  of  the  United  States  population 
and  are  therefore  used  to  compare  with 
incidence  rates  in  Louisiana.  The  1992-1996 
population  estimates  for  Louisiana  and  the  SEER 
areas  were  obtained  from  the  US  Bureau  of  the 
Census.  All  incidence  rates  were  age-adjusted 
to  the  1970  US  standard  population  to  remove 
the  influence  of  the  differences  in  age 
composition  among  populations  and  to  allow 
direct  comparison  of  cancer  incidence  between 
two  or  more  populations  with  different  age 
structures.  Age-adjusted  cancer  incidence  rates 
for  each  of  the  eight  Louisiana  regions  along  with 
the  entire  state  were  calculated  and  compared 
with  the  SEER  incidence  rates.  Rate  ratios  and 
standard  errors  were  also  computed  at  the  5% 
significance  level  for  determining  the  statistically 
significant  rate  differences.5 

RESULTS 

A total  of  14,293  new  cases  of  prostate  cancer 
were  diagnosed  in  Louisiana  during  1992-1996, 
approximately  2,900  cases  per  year.  Age- 
adjusted  incidence  rates  are  34%  higher  in 
African-American  men  than  in  their  white 
counterparts  and  this  difference  is  statistically 
significant.  The  incidence  rate  in  African- 
American  men  is  183.6  per  100,000  compared 
with  136.6  per  100,000  in  white  males.  Nationally, 
African  Americans  also  have  higher  incidence 
than  whites  (240.4  and  150.2  per  100,000).  The 
rates  for  both  races  in  Louisiana  men,  however, 
are  statistically  significantly  lower  than  the  SEER 
rates,  24%  lower  for  black  males  and  9%  lower 
for  white  males  (Figure  l).6 

Regional  comparisons  show  that,  in  general, 
Baton  Rouge  has  the  state's  highest  rates  for  both 
whites  and  African  Americans,  whereas  the 


Cancer  in  Louisiana 


250 


200 

o 

0 

1 150 


(1) 

ci  100 
0 
"(D 

cc 


50 


□ Louisiana  ■ SEER 


J 


Whites  Blacks  Whites  Blacks 

Incidence  Mortality 

Statistically  significantly  lower  than  the  SEER  rate. 


Figure  1.  Average  annual  age-adjusted  prostate  cancer  incidence  and  mortality  rates,  Louisiana 
and  SEER  by  race,  1992-1996. 


Table.  Prostate  Cancer  Incidence  Rates  by  Race*,  1992-1996 

Whites 

Blacks 

Geographic  Area 

Rate 

Standard 

Error 

Rate 

Ratio5 

Rate 

Standard 

Error 

Rate 

Ratio5 

Louisiana 

136.6 

1.36 

0.91* 

183.6 

2.89 

0.76* 

New  Orleans 

140.5 

2.96 

0.94* 

174.6 

5.47 

0.73* 

Baton  Rouge 

173.7 

3.92 

1.16* 

225.7 

7.84 

0.94 

Southeast  Louisiana 

130.1 

3.87 

0.87* 

151.1 

9.57 

0.63* 

Acadiana 

116.3 

3.42 

0.77* 

130.3 

7.22 

0.54* 

Southwest  Louisiana 

121.6 

4.76 

0.81* 

163.0 

12.85 

0.68* 

Central  Louisiana 

115.1 

4.45 

0.77* 

144.0 

10.30 

0.60* 

Northwest  Louisiana 

143.6 

3.91 

0.96 

217.0 

8.05 

0.90* 

Northeast  Louisiana 

121.1 

4.31 

0.81* 

193.6 

9.05 

0.81* 

SEER 

150.2 

0.55 

1.00 

240.4 

2.40 

1.00 

+Rates  are  per  100,000,  age  adjusted  to  the  U.S.  1970  stanadard  population 
§ Rate  ratio  represents  the  ratio  of  incidence  rates  between  Louisiana  and  SEER 
* Significantly  different  (P  < .05)  from  the  SEER  rate. 

J La  state  Med  Soc  VOL  152  April  2000  197 


Cancer  in  Louisiana 


lowest  rates  are  observed  in  Central  Louisiana 
for  whites  and  in  Acadiana  for  African 
Americans  (Table  1).  The  significantly  reduced 
prostate  cancer  incidence  patterns  observed  in 
Louisiana  overall  are  mirrored  in  each  of  the 
eight  regions  except  for  the  Baton  Rouge  region 
and  white  males  living  in  Northwest  Louisiana. 
The  rate  of  173.7  per  100,000  for  Baton  Rouge 
white  males  is  not  only  the  highest  rate  in  the 
entire  state,  but  16%  higher  than  the  SEER 


combined  rates  as  well. 

Like  many  other  cancers,  prostate  cancer  is 
rare  before  the  age  of  40.  Incidence  begins  to 
increase  gradually  after  age  40  and  rises  sharply 
in  men  55  years  of  age  and  older.  The  age-specific 
incidence  curves  for  Louisiana  whites  are  lower 
than  for  whites  living  in  the  SEER  areas,  but  the 
gap  between  the  two  curves  diminishes 
gradually  with  increasing  age  (Figure  2).  The 
curve  for  African  Americans  in  Louisiana  is 


Age  (years) 

Figure  2.  Average  annual  age-specific  prostate  cancer  incidence  rates,  Louisiana 
& SEER,  whites,  1992-1996. 


2000 


+ 

Age  (years) 


Figure  3.  Average  annual  age-specific  prostate  cancer  incidence  rates,  Louisiana  & 
SEER,  blacks,  1992-1996. 


198  J La  State  Med  Soc  VOL  152  April  2000 


Cancer  in  Louisiana 


Figure  4.  Prostate  and  lung  cancer  incidence  trends,  Louisiana  & SEER, 
whites,  1988-1996. 


Figure  5.  Prostate  and  lung  cancer  incidence  trends,  Louisiana  & 
SEER,  blacks,  1988-1996. 


consistently  lower  after  age  45  than  the  SEER 
curve  (Figure  3).  Interestingly,  for  both  races  the 
gap  between  the  age-specific  curves  gradually 
widens  up  to  age  70-75.  At  that  point  incidence 
rates  decline  in  the  SEER  areas  whereas  the 
Louisiana  males'  age-specific  incidence 
continues  to  rise  steadily  The  median  age  of 
prostate  cancer  is  70  for  whites  and  68  for  African 
Americans. 

Prostate  cancer  was  the  second  most 
common  cancer  after  lung  cancer  in  white  males 


nationally  until  1985  when  the  incidence  of 
prostate  cancer  first  exceeded  that  of  lung  cancer. 
It  has  remained  higher  since  then.  A similar 
pattern  is  evident  in  Louisiana  men  in  the  last 
decade,  where  prostate  cancer  rate  is  steadily 
increasing  while  lung  cancer  rate  started  to  drop 
off  (Figure  4).  Prostate  cancer  has  been  the 
leading  cancer  among  African  Americans 
nationally  since  the  inception  of  SEER  program 
in  1973.  In  fact,  they  have  the  world's  highest 
incidence  rate.  In  contrast,  Louisiana's  African- 


J La  State  Med  Soc  VOL  152  April  2000  199 


Cancer  in  Louisiana 


American  men  persistently  have  lower  rates  of 
prostate  cancer  while  their  lung  cancer  rates 
exceed  the  national  rates  for  all  race  / sex  groups 
by  a wide  margin  (Figure  5). 

Despite  their  significantly  lower  prostate 
cancer  incidence,  Louisiana  men  experience 
comparable  mortality  rates  to  those  nationally. 
During  1992-1996,  the  death  rate  from  prostate 
cancer  in  Louisiana  white  men  was  24.0, 
compared  to  23.5  in  the  United  States  per  100,000 
(Figure  1).  In  African  Americans,  the  rate  was 
53.6  in  Louisiana  and  54.8  in  the  United  States. 
When  incidence  to  mortality  ratios  are 
examined,  it  is  clear  that  Louisiana  men  of  both 
races  exhibit  poorer  survival  than  their 
counterparts  nationally  (Figure  6).  Incidence  to 
mortality  ratio  provides  a crude  estimate  of 
survival  pattern;  the  higher  the  ratio,  the  better 
the  survival.  It  is  important  to  note  that  the 
incidence  to  mortality  ratio  in  African-American 
men  is  lower  than  in  white  men  in  Louisiana 
and  is  lowest  compared  with  national  ratios  (3.4 


for  whites  and  5.7  for  African  Americans  in 
Louisiana;  4.4  and  6.4  respectively  in  the  United 
States). 

DISCUSSION 

Prostate  cancer  represents  the  most  common 
malignancy  in  the  US  male  population. 
Although  the  rate  of  disease  is  lower  in 
Louisiana  than  in  other  areas  of  the  country,  the 
incidence  of  prostate  cancer  is  increasing  here. 
Overall  incidence  has  increased  46%  since  1988 
and  this  is  due  relatively,  in  large  part,  to 
increased  screening.  It  is  expected  to  continue  a 
more  modest  increase  with  the  aging  of  the 
American  population.  The  incidence  gap 
between  Louisiana  and  SEER  whites  is 
diminishing  as  a result  of  declining  rates  of 
prostate  cancer  in  the  SEER  areas  while 
Louisiana  rates  remain  stable.  Unlike  whites,  the 
African  Americans  in  Louisiana  continue  to 


Figure  6.  Prostate  cancer  incidence-mortality  ratio,  Louisiana  & US,  1992-1996 
Note:  Higher  incidence-mortality  ratios  indicate  better  survival. 


200  J La  State  Med  Soc  VOL  152  April  2000 


Cancer  in  Louisiana 


experience  a lower  risk  of  prostate  cancer  than 
their  counterparts  in  the  SEER  areas. 
Nevertheless  African-American  men  in 
Louisiana  have  significantly  higher  rates  than 
whites.  This  racial  difference  in  cancer  incidence 
in  Louisiana  is  not  fully  understood.  The 
complex  relationship  between  race  and  socio- 
demographic  factors,  such  as  education,  income, 
access  to  health  care,  and  attitudes  and 
knowledge  about  prostate  specific  antigen  (PSA) 
screening  might  explain  some,  but  not  all,  of 
these  differences. 

Biologically,  prostate  cancer  is  often  indolent 
in  nature  and  remains  latent  and  innocuous  at 
the  onset  in  most  individuals.  But  the  advent  of 
a new  screening  tool,  PSA,  has  increased 
detection  of  this  cancer  in  its  early  stages.  As  a 
result,  increasing  numbers  of  prostate  cancer 
cases  are  now  diagnosed  in  outpatient  settings 
where  cancer  registration  in  state  registries  may 
be  less  complete.  The  low  prostate  cancer 
incidence  rates  for  1992-1996  may  result  either 
from  failure  to  capture  the  new  cases  diagnosed 
in  physicians7  clinics  or  accurately  reflect  a true 
low  incidence  in  Louisiana. 

Prostate  cancer  growth  is  stimulated  by 
androgens  and  high  hormone  levels  have  been 
linked  to  risk  for  the  disease  in  various 
populations.  Although  the  exact  causes  of 
prostate  cancer  are  not  yet  understood,  a number 
of  demographic,  genetic,  and  environmental 
factors  have  been  associated  with  risk  of  the 
disease.  Some  of  the  known  risk  factors  include 
age,  race,  and  family  history.7'9  The  cancer  has  a 
strong  positive  correlation  with  age.  In  addition, 
family  history  and  African-American  heritage 
are  found  to  be  the  most  significant  risk  factors 
for  prostate  cancer.  For  African-American  men, 
the  incidence  and  mortality  rates  are  nearly  twice 
those  of  other  racial  groups.  It  has  been 
suggested  that  African-American  men  present 
with  disease  in  more  advanced  stages  and  at 
younger  ages  and  are  less  likely  to  be  offered 
aggressive  treatment.1011  In  addition  to  known 
risk  factors,  a diet  high  in  fat,  particularly 
saturated  fat,  is  now  thought  to  play  an 
important  role  in  disease  progression.12,13 


Detection  of  cancer  at  its  early  stages  with 
prompt  provision  of  stage-appropriate  treatment 
can  improve  the  disease-free  survival  and 
quality  of  life  of  patients.  Overall  a shift  toward 
the  detection  of  cancer  in  its  early  stage  is  evident 
in  Louisiana,  but  African  Americans  have  twice 
the  proportion  of  late-stage  tumors  than  do 
whites.  Preliminary  analysis  of  Louisiana  Tumor 
Registry  data  shows  that  14.4%  of  African 
Americans  are  diagnosed  with  distant  stage  of 
disease  compared  with  6.3%  of  white  men. 
Currently  in  SEER  areas  the  5-year  relative 
survival  is  over  99%  when  prostate  cancer  is 
diagnosed  in  localized  or  regional  stages,  but 
survival  with  distant  stage  of  disease  remains 
poor  at  about  35%. 14  The  5-year  relative  survival 
for  African  Americans  is  even  lower,  93%  for 
localized  disease,  dropping  to  30%  when 
diagnosed  at  distant  stage.15 

Despite  the  fact  that  the  PSA  has  reasonable 
screening  test  characteristics  (sensitivity  and 
specificity),  the  best  application  of  this  screening 
test  continues  to  be  debated.  Poor  survival  of 
Louisiana  men,  particularly  African  Americans, 
highlights  the  need  for  effective  prostate  cancer 
control  and  prevention  programs.  Recognizing 
the  public  health  significance,  the  American 
Cancer  Society  (ACS)  has  proposed  a general 
guideline  for  those  who  are  at  increased  risk  of 
prostate  cancer.  The  ACS  recommends  PSA  and 
digital  rectal  examination  annually,  beginning 
at  50  years  of  age,  for  men  who  have  at  least  a 
10-year  life  expectancy  and  for  younger  men 
who  are  at  a high  risk,  such  as  African  Americans 
or  those  with  a family  history  of  prostate  or 
breast  cancer.  The  likelihood  of  adherence  to  this 
guideline  is  closely  related  to  access  to  health 
care,  which  is  in  turn  associated  with  the 
socioeconomic  status  of  the  patients.  Recent 
studies  have  shown  that  even  after  controlling 
for  socioeconomic  status,  African  Americans  are 
less  likely  than  whites  to  receive  health  care  or 
to  believe  that  cancer  is  preventable.16'18 
Culturally-sensitive  cancer  control  and 
prevention  programs,  therefore,  should  be 
developed  to  reach  the  disadvantaged  and 
minority  populations  in  Louisiana. 


J La  State  Med  Soc  VOL  152  April  2000  201 


Cancer  in  Louisiana 


To  reduce  prostate  cancer  mortality,  early 
detection  and  stage-specific  treatment  are 
crucial.  Treatment  modalities  for  prostate  cancer 
have  changed  in  recent  years  since  the 
introduction  of  PSA  screening.  The  Centers  for 
Disease  Control  and  Prevention  has  awarded  the 
Louisiana  Tumor  Registry  funding  to  collect 
baseline  treatment  and  PSA  screening 
information  for  a subset  of  Louisiana  men 
diagnosed  with  prostate  cancer.  LTR  staff  will 
contact  hospitals,  urologists,  and  oncologists  to 
obtain  information  on  complete  treatment  and 
on  factors  that  may  affect  treatment  decisions, 
such  as  PSA  screening  prior  to  the  diagnosis, 
Gleason's  grade,  and  existing  comorbidity.  This 
study  will  provide  baseline  estimates  of 
prognostic  indicators  and  pattern  of  care  in 
greater  detail  than  normally  collected.  The 
upcoming  study  should  provide  much  needed 
insights  into  prostate  cancer  in  the  state.  We  look 
forward  to  the  collaboration  of  the  medical 
community,  so  necessary  to  make  this  study  as 
success. 


REFERENCES 

1.  Landis  SH,  Murray  T,  Bolden  S,  et  al.  Cancer 
statistics,  1999.  Ca  Cancer  J Clin.  1999;49:8-31. 

2.  Andrews  PA,  Correa  CN,  Wu  XC,  et  al.  Cancer 
Incidence  and  Mortality  in  Louisiana,  1990-1994.  New 
Orleans:  Louisiana  Tumor  Registry;  1998.  (Cancer 
in  Louisiana;  Volume  10) 

3.  Parrish  P,  Fulton  JP,  Correa  CN,  et  al.  Exploring  the 
internal  consistency  of  registry  data  on  stage  of 
disease  at  diagnosis:  part  II:  cancer  of  the  prostate. 
In:  Chen  VW,  Wu  XC,  Andrews  PA  (editors).  Cancer 
in  North  America,  1991-95.  Volume  One:  Incidence. 
Sacramento,  Cal:  North  American  Association  of 
Central  Cancer  Registries;  1999:VI-1-VI-14. 

4.  Percy  C,  Van  Holten  V,  Muir  C (editors). 
International  classification  of  diseases  for  oncology,  2nd 
edition.  Geneva,  Switzerland:  World  Health 
Organization;  1990. 

5.  Breslow  NE,  Day  NE.  Statistical  methods  in  cancer 
research,  Vol.  2:  The  design  and  analysis  of  cohort 
studies.  Lyon,  France:  International  Agency  for 
Research  on  Cancer;  1987.  (IARC  Scientific  pub.  No. 
82.) 


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serenity— it’s  a different  way  of  life.  It’s  the 
home  we’ve  always  wanted. 77 


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202  J La  State  Med  Soc  VOL  152  April  2000 


Cancer  in  Louisiana 


6.  Ries  LAG,  Kosary  Cl,  Hankey  BF,  et  al  (editors) 
SEER  Cancer  Statistics  Review;  1973-1996.  Bethesda, 
Md:  National  Cancer  Institute;  1999. 

7.  Villeneuve  PJ,  Johnson  KC,  Kreiger  N,  et  al.  Risk 
factors  for  prostate  cancer:  results  from  the 
Canadian  National  Enhanced  Cancer  Surveillance 
System.  The  Canadian  Registries  Epidemiology 
Research  Group.  Cancer  Causes  Control  1999;10:355- 
367. 

8 . Pienta  KJ,  Esper  PS.  Risk  factors  for  prostate  cancer. 
Ann  Int  Med  1993;118:793-803. 

9.  Steinberg  GD,  Carter  BS,  Beaty  TH,  et  al.  Family 
history  and  the  risk  of  prostate  cancer.  Prostate 
1990;17:337. 

10.  Fowler  JE,  Terrell  F.  Survival  in  blacks  and  whites 
after  treatment  for  localized  prostate  cancer.  / Urol. 
1996;156:133. 

11.  Kim  JA,  Kuban  DA,  El-Mahdi  AM,  et  al. 
Carcinoma  of  the  prostate:  race  as  a prognostic 
indicator  in  definitive  radiation  therapy.  Radiology 
1995;194:545. 

12.  Meyer  F,  Bairati  I,  Shadmani  R,  et  al.  Dietary  fat 
and  prostate  cancer  survival.  Cancer  Causes  Control 
1999;10:245-251. 

13.  Schuurman  AG,  van  den  Brandt  PA,  Dor  ant  E,  et 
al.  Association  of  energy  and  fat  intake  with 
prostate  cancer  risk:  results  from  The  Netherlands 
Cohort  Study.  Cancer  1999;86:1019-1027. 

14.  Stanford  JL,  Stephenson  RA,  Coyle  LM,  et  al 
(editors).  Prostate  cancer  trends  1973-1995,  SEER 
Program.  National  Cancer  Institute.  Bethesda,  Md: 
National  Cancer  Institute;  1999.  [NIH  pub.  no.  99- 
4543] 

15.  Bolden  S,  Davis  KJ,  Landis  S,  et  al.  Cancer  Facts 
and  Figures  for  African  Americans  1998-1999 . 
American  Cancer  Society. 

16.  Sung  JF,  Bluementhal  DS,  Coates  RJ.  Knowledge, 
beliefs,  and  attitudes  and  cancer  screening  among 
inner  city  African-American  women.  J Natl  Med 
Assoc  1997;89:405-411. 

17.  Scroggins  TG,  Bartley  TK.  Enhancing  cancer 
control:  assessing  cancer  knowledge,  attitudes,  and 
beliefs  in  disadvantaged  communities.  / La  State 
Med  Soc  1999;151:202-208. 

18.  Denmark- Wahnefried  W,  Catoe  KE,  Paskett  E,  et 
al.  Characteristics  of  men  reporting  for  prostate 
cancer  screening.  Urology  1993;42:269-275. 


All  authors  are  faculty  members  in  the 
Department  of  the  Public  Health  & 
Preventive  Medicine,  Louisiana  State  University  Health 
Sciences  Center,  New  Orleans,  Louisiana. 

Drs  Ahmed,  Chen,  Wu,  and  Correa,  Ms  Andrews,  and 
Ms  Schmidt  are  also  the  central  staff  of  the  Louisiana 
Tumor  Registry,  New  Orleans,  Louisiana. 

Drs  Chen  and  Fontham  are  members  of  the 
Stanley  S.  Scott  Cancer  Center, 
LSU  Health  Sciences  Center, 
New  Orleans,  Louisiana. 


J La  State  Med  Soc  VOL  152  April  2000  203 


Calendar 


July  2000 


May  2000 


15-20  Society  for  Biomaterials,  USA  Sixth 
World  Biomaterials  Congress 
Kamuela,  Hawaii,  U.S.A.  Contact 
Rosealee  Lee  at  (612)  543-0908. 


June  2000 


3-7  Association  for  the  Advancement  of 
Medical  Instrumentation  2000 
Conference  & Expo,  San  Jose,  Cal. 
Contact  the  AAMI  at  (703)  525-1424  or 
visit  www.aami.org. 

9-10  The  IPA  Association  of  America,  2nd 
Annual  South  East  Regional 
Symposium,  New  Orleans,  La.  Contact 
TIPAAA  at  (51 0)  569-2753. 


7-9  The  Amputee  Coalition  of  America 
(ACA)  10th  Annual  Meeting  & 
Exposition,  Orlando,  Fla.  Contact  1-888- 
267-5669. 

19-22  The  45th  Annual  Southern  Obstetric 
and  Gynecologic  Seminar,  Asheville, 
NC.  Contact  Dr  George  T Schneider  at 
(504)  842-4155. 

27-30  Louisiana  Academy  of  Family 
Physicians  1st  Annual  Summer 
Breakaway,  Point  Clear,  Al.  Contact 
Anne  Cathey  of  LAFP  at  (225)  923-331 3, 
e-mail:  academy@lafp.org. 


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204  J La  State  Med  Soc  VOL  152  April  2000 


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It  is  About  More  Than  Just  the  Heart  for  the  American  Heart  Association 
Carotid  Stenting:  A Technology  in  Evolution 
Role  of  the  Catheter  in  the  Treatment  of  Cardiac  Arrhythmias 
Renovascular  Hypertension:  Screening  and  Therapeutic  Options 
Thrombolytic  Therapy  for  Acute  Ischemic  Stroke 
Percutaneous  Interventional  Approaches  to  Diseases  of  the  Aorta 


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Frank  M.  Sheridan,  MD  232  It  is  About  More  Than  Just  the  Heart 

for  the  American  Heart  Association; 
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235 

Carotid  Stenting: 

A Technology  in  Evolution 

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Role  of  the  Catheter  in  the 
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Edwin  Rivera,  MD 
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247 

Renovascular  Hypertension: 
Screening  and  Therapeutic  Options 

Roger  E.  Kelly,  MD 

253 

Thrombolytic  Therapy  for 
Acute  Ischemic  Stroke 

Dia  Abochamh,  MD 
Frank  M.  Sheridan,  MD 

259 

Percutaneous  Interventional  Approaches 
to  Diseases  of  the  Aorta 

212 

Jorge  I.  Martinez-Lopez,  MD  215 

William  O’Mara,  MD  218 

A.  Foster  Hebert,  MD 

Harold  Neitzschman,  MD  223 

Scott  Wilson,  MD 

Michael  M.  Sawyer,  MD  225 


INFORMATION  FOR  AUTHORS 

ECG  OF  THE  MONTH 
Not  So  Obvious 

OTOLARYNGOLOGY/HEAD  & NECK 
SURGERY  REPORT 
External  Laryngeal  Trauma 

RADIOLOGY  CASE  OF  THE  MONTH 
My  Aching  Hip 

HISTORY  OF  MEDICINE 
A Grits  Mill:  The  Story  of 
Field  Memorial  Hospital 


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230  LSMS  ALLIANCE 

Of  Course  Change  is  a Risk  . . . 

268  CALENDAR 

269  CLASSIFIED  ADVERTISING 


J La  State  Med  Soc  VOL  152  May  2000 


When  Lou  Gehrig's  widow  chose  an  organization  to  lead  the  fight 
against  amyotrophic  lateral  sclerosis  — the  muscle-wasting  disease  that 
killed  her  husband  — she  selected  the  Muscular  Dystrophy  Association. 

Since  the  time  she  served  as  MDA  national  campaign  chairman,  the 
Association  has  consistently  led  the  battle  against  ALS.  MDA  maintains 
the  world's  largest  nongovernmental  ALS  research  and  patient  services 
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People  Help  MDA. ..Because  MDA  Helps  People 


ECG  of  the  Month 


Not  So  Obvious 

Jorge  I.  Martinez-Lopez,  MD 


The  six  limb  leads  shown  below  belong  to  a 65-year-old  woman;  the  leads  were 
not  recorded  simultaneously.  The  patient  presented  to  the  hospital  with  a 2-week 
history  of  recurrent  episodes  of  dizziness  and  exertional  dyspnea.  She  was  taking 
no  medications. 


What  is  your  diagnosis? 

Elucidation  begins  on  page  216. 

J La  State  Med  Soc  VOL  152  May  2000  215 


ECG  of  the  Month 
Presentation  is  on  page  215. 

DIAGNOSIS  - Complete  AV  block 

Because  all  six  leads  essentially  show  the  same 
abnormalities,  analysis  of  the  tracing  will  focus 
primarily  on  limb  lead  II. 

The  ventricular  rhythm  is  regular  and  the 
rate  is  brady cardiac,  at  34  times  a minute.  QRS 
complexes  are  narrow  and  measure  0.08  sec.  The 
atrial  rhythm  (P  waves)  is  also  regular,  but  at  75 
times  a minute.  P waves,  which  are  broad  and 
notched  in  lead  II,  have  no  constant  temporal 
relationship  to  the  narrow  QRS  complexes;  this 
explains  the  variable  length  of  the  PR  intervals. 
Therefore,  the  dominant  feature  of  the  tracing, 
at  this  point  in  the  analysis,  is  the  regularity  of 
the  atrial  and  ventricular  rhythms,  at  different 
rates,  with  no  evidence  that  AV  conduction  takes 
place.  This  ECG  abnormality  falls  under  the 
category  of  AV  dissociation  (AVD). 

AVD,  however,  is  not  a final  ECG  diagnosis; 
it  is  merely  a descriptive  term.  It  requires  a pre- 
cise definition  of  the  mechanism  responsible  for 
it,  because  AVD  can  occur  in  a variety  of  clinical 
situations.  When  the  atrial  rate  is  faster  than  the 
ventricular  rate,  AVD  is  almost  always  caused 
by  complete  AV  block.  On  the  other  hand,  when 
the  ventricular  rate  exceeds  the  atrial  rate,  AVD 
is  usually  secondary  to  either  acceleration  of  a 
subsidiary  pacemaker  in  the  AV  junctional  tis- 
sues or  in  the  ventricle  to  a rate  faster  than  the 
sinus  rate  (AVD  by  usurpation),  or  to  slowing 
of  the  sinus  rate  below  the  normal  escape  rate 
of  subsidiary  pacemakers  or  of  an  implanted 
ventricular  demand  pacemaker  (AVD  by  de- 
fault). The  findings  present  in  the  tracing  are 
consistent  with  the  diagnosis  of  AVD  second- 
ary to  complete  AV  block  (CAVB).  It  should  be 
clear  that  the  terms  AVD  and  CAVB  are  neither 
synonymous  nor  interchangeable. 

The  regularly  recurring  narrow  QRS 
complexes  at  slow  rates  indicate  that  the 
ventricles  are  driven  by  an  escape  focus,  in 
which  electrical  impulses  originate  in  the  AV 
junctional  tissues  or  the  bundle  of  His.  This,  in 


itself,  is  an  interesting  finding,  given  this 
patient's  age.  Escape  rhythms  with  narrow  QRS 
complexes  are  found  most  frequently  in  younger 
patients  with  congenital  CAVB,  with  or  without 
coexisting  organic  heart  disease.  Acquired  CAVB, 
on  the  other  hand,  is  a complication  of  long- 
standing structural  heart  disease  in  older 
patients.  QRS  complexes  are  usually  wide 
because  the  level  of  block  is  in  the  distal 
intraventricular  conduction  system  and  the 
escape  rhythm  originates  in  the  ventricle. 

The  broad,  notched  P waves  found  in  lead  II 
are  "pathologic".  In  most  instances,  such  P 
waves  may  be  recorded  in  patients  with  either 
left  atrial  enlargement  or  hypertrophy,  or  both, 
and  in  interatrial  conduction  block.  Rarely,  this 
type  of  P wave  may  be  found  in  normal  subjects. 

Two  other  ECG  findings  are  clearly  obvious: 
first,  the  QT  interval  is  prolonged  to  0.64  sec; 
second,  T waves  are  broad-based,  and  inverted 
in  leads  I,  II,  and  AVL.  The  clinical  significance 
of  these  findings  in  a given  tracing  is  dependent 
on  a number  of  extrinsic  and  / or  intrinsic  factors. 
Recall  also  that  ventricular  bradycardia  of  any 
origin  may  cause  excessive  prolongation  of  the 
QT  interval.  Such  prolongation  of  the  QT  interval 
may  place  the  patient  at  increased  risk  for 
developing  potentially  lethal  ventricular 
arrhythmias. 

Finally,  what  ECG  finding  is  not  so  obvious? 
To  answer  this  question,  P-P  intervals  must  be 
measured  in  any  or  all  of  the  six  leads.  This 
simple  maneuver  reveals  the  "not  so  obvious": 
P-P  cycles  show  variations  in  their  length.  In 
some  instances,  P-P  cycles  that  include  a QRS 
are  shorter  than  P-P  cycles  that  do  not  include  a 
QRS.  At  other  times,  the  reverse  is  true.  In  other 
words,  P-P  cycles  with  a QRS  in  them  are  equal 
to  or  longer  than  those  without  a QRS. 
Diagnostic  consideration  should  be  given  to  two 
benign  possibilities:  sinus  arrhythmia  and 
ventriculophasic  arrhythmia  (VPA). 

Sinus  arrhythmia  is  a normal  variant  in 
which  the  sinus  rate  varies  with  respiration 
(phasic  sinus  arrhythmia)  or  has  no  relationship 
to  respiration  (non-phasic  sinus  arrhythmia).  It 
is  probably  produced  by  variations  in  tone  of 


216  J La  State  Med  Soc  VOL  152  May  2000 


the  autonomic  nervous  system.  In  contrast,  VPA 
differs  from  sinus  arrhythmia  in  that  P-P  cycles 
that  include  a QRS  are  " always"  shorter  than  P- 
P cycles  that  do  not.  This  phenomenon  is  found 
in  approximately  30%  of  patients  with  CAVB, 
regardless  of  the  site  of  block.  The  variation 
found  in  this  tracing  is  sinus  arrhythmia. 

Following  implantation  of  an  artificial  car- 
diac pacemaker,  the  patient's  symptoms  disap- 
peared and  her  quality  of  life  improved. 


Dr  Martinez-Lopez  is  a specialist  in  cardiovascular 
diseases  affiliated  with  the  Cardiology  Service,  Depart- 
ment of  Medicine,  Texas  Tech  University  Health  Sciences 
Center  and  Thomason  General  Hospital  in  El  Paso,  Texas. 


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J La  State  Med  Soc  VOL  152  May  2000  217 


Otolary  ~ "jy  / 




External  Laryngeal  Trauma 

William  O’Mara,  MD  and  A.  Foster  Hebert,  MD 


External  laryngeal  trauma,  blunt  or  penetrating,  is  a rare  but  potentially  life-threatening 
injury.  This  is  frequently  seen  in  multiple-trauma  patients  and  can  go  unrecognized  in 
the  absence  of  astute  clinical  awareness.  Injuries  may  range  from  small  endolaryngeal 
hematomas  or  lacerations  to  complete  laryngotracheal  separation.  Proper  airway 
management  is  of  utmost  importance  and  is  one  of  the  most  controversial  aspects  of 
treatment  of  laryngeal  trauma.  Flexible  fiberoptic  laryngoscopy  and  high  resolution 
computed  tomography  scanning  of  the  larynx  has  greatly  enhanced  the  evaluation  of 
these  injuries.  Treatment  options  range  from  conservative,  nonsurgical  observation  to 
evaluation  in  the  operating  room.  Surgical  intervention  may  involve  endoscopy,  open 
surgical  exploration,  and  possibly  laryngeal  stenting.  Long-term  goals  are  aimed  at 
maintaining  voice,  airway,  and  swallowing  ability.  A systematic  approach  to  this 
condition  often  results  in  predictable  and  acceptable  outcomes. 


Laryngeal  trauma  is  a rare  injury,  and  two 
main  factors  account  for  this.  First,  the 
larynx  is  located  posteriorly  in  relation 
to  the  mandible  and  sternum,  which  protect  it 
from  blunt  forces.  Also,  it  is  primarily 
cartilagenous  and  relatively  mobile.  This  allows 
it  to  absorb  a significant  amount  of  energy  di- 
rected toward  it.  The  incidence  has  been  esti- 
mated at  approximately  1/30,000  emergency 
department  visits.1  The  mortality  rate  has  been 
reported  at  approximately  2%.  About  75%  of 
patients  are  males  with  an  average  age  of  37.2 
Some  investigators  have  noticed  an  increasing 
trend  in  penetrating  laryngeal  trauma  compared 
to  blunt  trauma,  while  others  have  found  them 
to  occur  with  equal  incidence.1'3 

This  type  of  injury  can  be  classified  as  ei- 


ther blunt  or  penetrating.  Blunt  trauma  is  often 
the  result  of  motor  vehicle  crashes.  Frequently 
the  mechanism  is  a rear-end  collision  in  which 
the  driver  and  passenger  are  hit  from  behind. 
This  causes  hyperextension  of  the  neck,  forward 
propulsion,  and  blunt  force  to  the  anterior  neck 
against  the  steering  wheel  or  dashboard.  This 
compresses  the  laryngeal  skeleton  against  the 
foreign  object  and  the  anterior  cervical  spine, 
thereby  splaying  the  thyroid  cartilage  alae.4  This 
is  why  many  thyroid  cartilage  fractures  are  ver- 
tically oriented  and  median  or  paramedian. 
Other  blunt  injuries  are  the  clothesline  injuries 
seen  in  contact  sports  or  motorcycle  and  all-ter- 
rain vehicle  accidents.  Such  injuries  can  result 
in  complete  laryngotracheal  separation.  Pen- 
etrating laryngeal  trauma  is  commonly  due  to 


218  J La  State  Med  Soc  VOL  152  May  2000 


gunshot  or  stabbing  incidents.  High  velocity 
gunshot  wounds  cause  extensive  tissue  damage. 
The  zone  of  injury  may  be  much  larger  than 
appreciated  on  initial  evaluation.  Another  type 
of  injury  is  strangulation,  which  may  result  in 
multiple  cartilagenous  fractures  without  imme- 
diate mucosal  lacerations  or  hematomas. 

INITIAL  EVALUATION 

In  patients  with  no  acute  breathing  difficulties, 
it  is  important  to  obtain  a history  in  addition  to 
careful  physical  examination.  Understanding  the 
mechanism  of  injury  is  useful  in  estimating  the 
forces  incurred  on  the  laryngeal  framework, 
hence  the  severity  of  the  injury.  This  may  not  be 
possible  in  the  acutely  deteriorating  airway.  The 
first  step  in  all  cases  is  securing  an  airway,  as 
described  later,  followed  by  treatment  of  other 
life-threatening  injuries. 

The  presenting  symptoms  of  laryngeal 
trauma  include  voice  change,  pain,  hoarseness, 
stridor,  dysphagia,  odynophagia,  and  hemop- 
tysis. Signs  of  laryngeal  trauma  are  edema  of  the 
anterior  neck,  crepitance,  subcutaneous  emphy- 
sema, ecchymosis,  loss  of  the  thyroid  cartilage 
prominence,  palpable  cartilage  fracture,  or  an 
open  neck  wound  with  exposed  cartilage.5  Af- 
ter establishing  a secure  airway,  laryngologic 
examination  is  performed  as  soon  as  possible. 
Flexible  fiberoptic  laryngoscopy  is  the  preferred 
method  of  initial  evaluation.  Signs  of  injury  in- 
clude edema,  submucosal  hematomas,  mucosal 
lacerations,  exposed  cartilage,  impaired  vocal 
cord  mobility,  or  gross  deformity  of  the  larynx.1 

Laryngeal  trauma  is  frequently  a delayed 
diagnosis.  Patients  who  have  sustained  laryn- 
geal trauma  may  appear  deceptively  normal  in 
the  immediate  hours  following  injury.  To  further 
compound  this,  these  patients  often  sustain  as- 
sociated injuries  which  can  be  distracting  in  the 
initial  evaluation.  They  include  skull  base  or  in- 
tracranial injuries  (13%  to  28%),  cervical  spine 
injuries  (8%  to  14%),  esophageal /pharyngeal 
injuries  (3%  to  14%),  and  open  neck  injury  (9%).2 

The  diagnostic  imaging  procedure  of  choice 
in  evaluating  laryngeal  injuries  is  high-resolu- 


tion computed  tomography  scanning  of  the  lar- 
ynx. Lateral  neck  soft  tissue  x-ray  films  are  usu- 
ally not  helpful  unless  there  is  suspicion  of  a 
foreign  body.  The  decision  to  obtain  a CT  is 
based  on  significant  mechanism  of  injury  or 
presence  of  physical  signs  of  injury  including 
hematoma,  edema,  or  laryngeal  tenderness. 
Some  authors  feel  that  CT  scanning  of  the  lar- 
ynx is  not  necessary  if  there  is  massive  laryn- 
geal trauma,  which  obviously  requires  surgical 
treatment.6  Others  routinely  obtain  CT  scans  of 
laryngeal  injuries  to  provide  operative  guid- 
ance.1 Findings  on  CT  scans  include  thyroid  car- 
tilage fractures,  cricoid  fractures,  hematoma  for- 
mation, subcutaneous  emphysema,  and  edema. 

AIRWAY  MANAGEMENT 

Those  with  an  acutely  deteriorating  airway  ne- 
cessitate immediate  action.  Airway  management 
of  these  patients  is  one  of  the  most  controversial 
aspects  of  treating  laryngeal  trauma.  The  goal  is 
to  establish  an  airway  by  the  least  traumatic 
method.  In  some  situations,  the  only  option  may 
be  to  simply  intubate  the  patient.  However,  at- 
tempts at  intubation  may  result  in  a false  pas- 
sage, further  disrupt  damaged  mucosa,  and  fur- 
ther compromise  the  airway.  Some  authors 
maintain  that  airway  management  can  be  per- 
formed by  experienced  personnel,  under  direct 
visualization,  and  with  a smaller  sized  endotra- 
cheal tube.7  It  is  generally  agreed,  however,  that 
if  there  is  any  question  whether  intubation  will 
be  difficult  or  dangerous,  an  awake  tracheotomy 
should  be  performed  under  local  anesthesia.  If 
time  does  not  allow  this,  cricothyroidotomy  can 
be  performed  with  conversion  to  a tracheotomy 
as  soon  as  possible.8 

Special  considerations  exist  in  the  pediatric 
patient.  Children  have  more  pliable  cartilage, 
which  resists  fracture,  but  are  more  predisposed 
to  suffer  greater  soft  tissue  injury,  edema,  and 
hematoma  formation.  Furthermore,  with  smaller 
dimensions  for  the  pediatric  airway,  such  swell- 
ing can  more  likely  result  in  airway  compromise. 
Elective  intubation  is  potentially  dangerous  and 
not  recommended.  A child  is  less  likely  to  be 


J La  State  Med  Soc  VOL  152  May  2000  219 


cooperative  to  undergo  tracheotomy  under  lo- 
cal anesthesia.  It  is  therefore  recommended  that 
they  undergo  tracheotomy  over  a ventilating 
bronchoscope  in  the  operating  room.9 

TREATMENT 

In  general,  laryngeal  injuries  are  managed  either 
non-operatively  or  surgically.  The  decision  to 
medically  manage  a laryngeal  injury  should  be 
based  on  the  likelihood  that  the  injury  would 
resolve  without  surgical  intervention.  Such  situ- 
ations include  very  minor  injuries  with  minor 
hematomas  and  small  mucosal  lacerations  (<1 
cm)  that  do  not  involve  the  anterior  commissure. 
Some  authors  also  treat  single  non-displaced 
thyroid  fractures  non-operatively  because  of  the 
likelihood  that  these  injuries  will  not  compro- 
mise the  voice.10 

Treatment  consists  of  at  least  24-hour  close 
inpatient  monitoring  and  includes  humidified 
air,  voice  rest,  and  head  of  bed  elevation.  Anti- 
biotics and  7-10  days  of  nasogastric  tube 
feedings  are  thought  to  facilitate  healing  of  mu- 
cosal tears.  H2 blockers  may  be  helpful,  particu- 
larly in  patients  with  gastroesophageal  reflux  to 
prevent  irritation  of  mucosal  injuries  and  pos- 
sible laryngeal  stenosis.  Early  use  of  steroids  may 
reduce  edema  but  is  of  no  proven  benefit.  Serial 
flexible  laryngoscopic  examinations  are  per- 
formed to  monitor  any  changes  in  the  airway 
during  treatment.8 

Surgical  options  can  be  divided  into  three 
broad  categories.  These  include  direct  endos- 
copy, endoscopy  with  exploration,  and  endos- 
copy with  exploration  and  stenting.  As  stated 
earlier,  the  compromised  airway  is  best  managed 
by  tracheotomy.  Once  an  airway  is  established 
and  other  life-threatening  injuries  are  treated, 
direct  laryngoscopy  should  be  performed.  This 
includes  rigid  esophagoscopy  to  rule  out  coin- 
cidental esophageal  and  pharyngeal  injuries. 
Endoscopy  is  also  recommended  if  there  is  any 
doubt  as  to  the  degree  of  injury,  after  flexible 
laryngoscopy  and  imaging  are  complete.  Trache- 
otomy is  sometimes  performed  at  the  time  of 
endoscopy,  due  to  potential  subsequent  swell- 


ing from  both  the  injury  and  endoscopic  ma- 
nipulation. If  findings  at  endoscopy  are  minor, 
such  as  small  hematomas  or  small  mucosal  lac- 
erations not  involving  the  anterior  commissure, 
and  with  mobile  vocal  cords,  no  further  surgi- 
cal intervention  is  required.1 

Several  findings  warrant  surgical  explora- 
tion. Indications  are  large  mucosal  lacerations 
(>1  cm),  exposed  cartilage,  vocal  cord  immobil- 
ity, cricoid  cartilage  fracture,  lacerations  of  the 
anterior  commissure  or  free  margin  of  a vocal 
fold,  multiple  or  displaced  cartilage  fractures, 
or  disruption  of  the  cricoarytenoid  joint.  The  lar- 
ynx is  explored  via  a midline  thyrotomy  or  laryn- 
gofissure.  The  larynx  may  also  be  entered 
through  a vertical  thyroid  cartilage  fracture  if  it 
exists  within  2-3  mm.  of  the  midline.  The  mid- 
line laryngeal  mucous  membrane  is  then  incised 
from  the  cricothyroid  to  the  thyrohyoid  mem- 
branes.4 

Repair  of  endolaryngeal  soft  tissue  injuries 
is  carried  out  in  a systematic  approach.  In  pen- 
etrating injuries  with  destruction  of  tissue,  a con- 
servative debridement  may  be  necessary.  Repair 
of  mucosal  lacerations  is  performed  in  a poste- 
rior to  anterior  direction,  and  exposed  cartilage 
should  be  covered  primarily  or  with  local  mu- 
cosal flaps.  Absorbable  suture  is  used  with  knots 
positioned  outside  the  laryngeal  lumen  to  pre- 
vent granulation  tissue  formation. 

Laryngeal  framework  repair  may  include 
reducing  arytenoid  cartilage  dislocations,  reat- 
taching an  avulsed  epiglottis,  and  reducing  and 
stabilizing  thyroid  and  cricoid  fractures.  Several 
methods  exist  for  fracture  repair  and  include  use 
of  stainless  steel  wire  (24  or  26  gauge),  absorb- 
able suture,  and  miniplates. 1'3'7'8,11 

When  there  is  risk  of  webbing,  scarring,  or 
collapse  of  the  cartilagenous  framework  despite 
exploration  and  repair,  a laryngeal  stent  is  rec- 
ommended. Indications  are  disruption  of  the 
anterior  commissure,  comminuted  laryngeal 
fractures,  and  massive  mucosal  injuries.  Stents 
can  be  made  with  a shortened  Portex  endotra- 
cheal tube  sewn  closed  at  both  ends,  manufac- 
tured silastic  stents,  or  by  use  of  a finger  cot  filled 
with  sponge  rubber.  Some  authors  feel  that  soft 


220  J La  State  Med  Soc  VOL  152  May  2000 


stents  such  as  finger  cots  increase  infection  and 
formation  of  granulation  tissue,  and  therefore 
use  the  molded  Portex  endotracheal  tube.1'8 
Stents  should  be  relatively  soft  to  prevent  mu- 
cosal injur}?-.  They  should  reach  from  the  false 
vocal  cords  to  the  first  tracheal  ring  and  mirror 
the  configuration  of  the  endolarvnx.  Lastly,  they 
should  be  stabilized  within  the  larynx  with  su- 
ture or  wire  brought  out  anteriorly  through  the 
cervical  skin  and  stabilized  with  a button.  It  is 
generally  agreed  that  stents  should  not  be  left  in 
for  longer  than  2 to  3 weeks.1- Removal  of  stents 
is  performed  under  general  anesthesia  with  con- 
comitant laryngoscopy.  At  the  time  of  stent  re- 
moval, the  carbon  dioxide  laser  can  be  utilized 
to  remove  any  immature  scar  or  granulation  tis- 
sue. Repeat  larvngoscopic  evaluations  are  per- 
formed until  an  adequate  airway  and  voice  is 
obtained." 

A unique  injury  is  laryngotracheal  separa- 
tion. This  type  of  injury  usually  results  in  im- 
mediate death.  However,  occasionally  the  air- 
way may  still  maintain  a tenuous  patency  with 
an  intact  mucosal  layer.  Airway  management  of 
this  condition  is  also  by  awake  tracheotomy 
under  local  anesthesia,  but  some  authors  report 
success  with  careful  bronchoscopic  intubation. 
In  laryngotracheal  separation,  bilateral  recurrent 
laryngeal  nerve  injur}7  and  subglottic  stenosis  is 
common.  Surgical  repair  involves  placement  of 
permanent  sutures  between  the  cricoid  and  sec- 
ond tracheal  ring  for  airway  support.4 

Severe  wounds  involving  the  larynx  may 
result  in  extensive  soft  tissue  and  framework 
loss.  Treatment  of  these  injuries  may  consist  of 
partial  or  total  laryngectomy.  Many  of  the  same 
principles  for  partial  laryngectomy  for  carci- 
noma can  be  applied  to  injuries  confined  to  the 
supraglottis  or  hemilarvnx.13 

OUTCOMES 

Outcomes  of  treatment  consist  of  evaluating 
quality  of  airway,  voice,  and  swallowing  ability. 
Airway  status  is  considered  poor  if  the  patient 
cannot  be  decannulated,  fair  if  there  is  mild  as- 
piration or  exercise  intolerance,  and  good  if  it 


resembles  the  preinjury  status.  Voice  is  usually 
labeled  as  poor  if  it  represents  aphonia  or  whis- 
per, fair  if  it  is  functional  but  different  or  hoarse, 
and  good  if  normal.  Swallowing  function  is  ei- 
ther normal  or  abnormal,  based  on  the  patient's 
subjective  report.1 

The  subjective  nature  of  results  does  limit 
comparison  of  studies,  but  injuries  managed 
conservatively  can  expect  to  yield  a good  air- 
way and  voice  in  approximately  90%  to  100% 
and  80%  to  90%  of  cases.  Injuries  managed  sur- 
gically are  obviously  more  severe  in  nature,  and 
the  rate  of  suboptimal  outcomes  increases  with 
the  extent  of  injur}7.  Surgically  treated  patients 
without  stenting  have  been  shown,  in  one  study, 
to  have  a good  airway  and  voice  in  84%  and  89% 
of  cases.  When  stents  were  used  after  surgical 
repair,  good  airway  results  were  found  in  80%, 
and  good  voice  results  were  found  in  only  40% 
of  cases.  Almost  all  patients  (98%),  however, 
could  be  decannulated,  and  100%  had  normal 
swallowing.  The  duration  of  stenting  has  de- 
creased over  the  years.  Two  to  3 weeks  duration 
of  laryngeal  stenting  has  produced  favorable 
results  compared  with  stenting  left  in  for  a longer 
duration.1'12 

Vocal  cord  paralysis  has  also  been  shown  to 
adversely  affect  outcome.  Ninety-six  percent  of 
patients  with  mobile  vocal  cords  had  excellent 
airway,  while  only  75%  of  patients  had  excel- 
lent airway  if  one  or  both  cords  were  immobile.12 
Blunt  and  penetrating  trauma  occur  with  simi- 
lar frequency  and  have  not  consistently  shown 
any  difference  in  outcomes. 

Another  factor  in  improving  outcome  is  the 
timing  of  exploration  and  repair.  This  has  been 
debated  in  the  past,  but  it  is  now  generally 
agreed  that  early  intervention  (24-48  hours  af- 
ter injurv7)  improves  results.  It  allows  a more 
accurate  assessment  of  injurv7  and  helps  prevent 
uncontrolled  healing  of  mucosal  lacerations, 
which  can  result  in  granulation  tissue  formation, 
scarring,  and  stenosis.  Numerous  studies  show 
that  early  intervention  decreases  voice  and  air- 
way complications  by  approximated  20%  to 
40%.1'8'12 


J La  State  Med  Soc  VOL  152  May  2000  221 


CONCLUSION 

External  laryngeal  trauma  is  a rare  injury  that 
can  be  managed  in  a careful  systematic  manner. 
The  use  of  flexible  fiberoptic  laryngoscopy  and 
CT  scanning  has  enabled  a very  accurate  assess- 
ment of  these  injuries.  Critical  points  of  treat- 
ment are  safely  establishing  the  airway  and  ad- 
equately restoring  the  function  of  the  larynx. 
Such  treatment  includes  awake  tracheotomy 
under  local  anesthesia  for  those  in  respiratory 
distress,  early  surgical  intervention,  and 
reapproximation  of  normal  laryngeal  anatomy. 
In  general,  almost  all  patients  with  external  la- 
ryngeal trauma  can  be  expected  to  have  a 
decannulated  airway,  a functional  voice,  and 
normal  swallowing. 

REFERENCES 

1.  Bent  JP,  Silver  JR,  Porubsky  ES.  Acute  laryngeal 
trauma:  a review  of  77  patients.  Otolaryngol  Head 
Neck  Surg  1993;109:441-449. 

2.  Jewett  BS,  Shockley  WW,  Rutledge  R.  External  la- 
ryngeal trauma  analysis  of  392  patients.  Arch 
Otolaryngol  Head  Neck  Surg  1999;125:877-880. 

3.  Schaefer  SD.  Acute  management  of  laryngeal 
trauma:  update.  Ann  Otol  Rhinol  Laryngol 
1989;98:98-104. 

4.  Schaefer  SD,  Stringer  S.  Laryngeal  trauma.  In: 
Bailey  BJ,  Pillsbury  HC,  Tardy  ME,  et  al  (editors). 
Head  Neck  Surgery-Otolaryngology , 2nd  edition.  Bal- 
timore: Lippincott  Williams  & Wilkins;  1998:947- 
957. 

5.  Schild  JA,  Denneny  EC.  Evaluation  and  treatment 
of  acute  laryngeal  fractures.  Head  Neck  1989;11:491- 
496. 

6.  Schaefer  SD.  Use  of  CT  scanning  in  the  manage- 
ment of  the  acutely  injured  larynx.  Otolaryngol  Clin 
North  Am  1991;24:31-35. 

7.  Gussack  GS,  Jurkovich  GJ,  Luterman  A.  Laryn- 
gotracheal trauma:  a protocol  approach  to  a rare 
injury.  Laryngoscope  1986;96:660-665. 

8.  Schaefer  SD.  The  treatment  of  acute  external  laryn- 
geal injuries.  Arch  Otolaryngol  Head  Neck  Surg 
1991;117:35-39. 

9.  Gold  SM,  Gerber  ME,  Shott  SR,  et  al.  Blunt  laryn- 
gotracheal trauma  in  children.  Arch  Otolaryngol 
Head  Neck  Surg  1997;123:83-87. 

10.  Stanley  RB,  Cooper  DS,  Florman  SH.  Phonatory 
effects  of  thyroid  cartilage  fractures.  Ann  Otol  Rhinol 
Laryngol  1987;96:493-496. 


11.  Pou  AM,  Shoemaker  DL,  Carrau  RL,  et  al.  Repair 
of  laryngeal  fractures  using  adaption  plates.  Head 
Neck  1998;20:707-713. 

12.  Leopold  DA.  Laryngeal  trauma.  A historical  com- 
parison of  treatment  methods.  Arch  Otolaryngol 
Head  Neck  Surg  1983;109:106-111. 

13.  Potter  CR,  Sessions  DG,  Ogura  JH.  Blunt  laryngotra- 
cheal trauma.  Trans  Am  Assoc  Ophthalmol  Otolaryngol 
1978;86:909-923. 


Dr  O'Mara  is  a resident  in  the  Department  of 
Otolaryngology-Head  and  Neck  Surgery , Tulane 
University  Medical  Center,  in  New  Orleans,  Louisiana. 

Dr  Hebert  is  an  assistant  professor  of  Otolaryngology- 
Head  and  Neck  Surgery,  Tulane  University  Medical  Center 
in  New  Orleans,  Louisiana,  and  Chief  of  Otolaryngology- 
Head  and  Neck  Surgery,  Veterans  Administration  Medical 

Center  in  Biloxi,  Mississippi. 


222  J La  State  Med  Soc  VOL  152  May  2000 


— — — — — ^ __  — 1 


My  Aching  Hip 

Harold  Neitzschman,  MD  and  Scott  Wilson,  MD 


A 21-year-old  man  presented  with  a 3-month  history  of  right  hip  pain,  worse  at  night  and 
without  fever. 


Figure  la.  AP  of  pelvis. 


Figure  1 b.  CT  scan  of  right  hip. 


What  is  your  diagnosis? 
Elucidation  is  on  page  224. 


J La  State  Med  Soc  VOL  152  May  2000  223 


Radiology  Case  of  the  Month 
Case  Presentation  is  on  page  223. 

RADIOLOGIC  DIAGNOSIS  - Intraarticular 
osteoid  osteoma 

PATHOLOGIC  DIAGNOSIS  - Same 

INTERPRETATION  OF  IMAGING 

Figure  1 is  an  AP  of  the  pelvis,  which  fails  to 
demonstrate  any  bony  changes.  Because  of  the 
suspicion  of  osteoid  osteoma  of  the  right  hip  a 
CT  scan  was  obtained.  Figure  2 is  a CT  study 
which  demonstrates  the  nidus  seen  within  the 
intracapsular  portion  of  the  right  hip. 

DISCUSSION 

The  etiology  of  osteoid  osteoma  is  unknown. 
The  lesion  is  not  true  tumor  and  contains  a 
highly  vascular  nidus  along  with  fibrous  tissue. 
The  nidus  is  usually  less  than  1 centimeter  and 
is  frequently  surrounded  by  a zone  of  sclerotic 
bony  reaction.  Identification  of  the  nidus  is  the 
key  to  diagnosing  this  entity.  The  lesion  may  be 
cortical,  medullary,  or  periosteal  in  location.  The 
surrounding  sclerotic  reaction  is  less  intense 
when  located  within  the  medullary  area  of  the 
bone.  The  nidus  may  be  lucent  or  may  be  par- 
tially or  totally  calcified.  A second  nidus  may 
occur  within  bone  adjacent  to  the  initial  nidus. 

When  the  lesion  is  intraarticular  the  main 
presentation  is  secondary  to  a lymphofollicular 
synovitis  causing  significant  joint  swelling  and 
pain  and  may  simulate  infectious  or  rheuma- 
toid arthritis.  The  diagnosis  of  intraarticular  os- 
teoid osteoma  is  usually  difficult  because  bony 
sclerotic  reaction  is  usually  not  present  and 
identification  of  the  nidus  may  only  be  seen  on 
evaluation  by  computerized  tomography. 

The  onset  of  symptoms  is  most  often  seen 
in  the  second  or  third  decade  of  life.  The  lesion 
is  seen  twice  as  commonly  in  men  as  in  women. 
Signs  and  symptoms  of  extraarticular  osteoid 
osteoma  include  pain  worse  at  night  and  usu- 
ally relieved  by  aspirin.  Intraarticular  osteoid 
osteoma  pain  usually  does  not  respond  to  aspi- 


rin. Spinal  lesions  are  uncommon,  usually  oc- 
cur in  the  posterior  elements,  and  may  result  in 
scoliosis. 

In  addition  to  radiographs,  evaluation  by 
computerized  tomography  and  bone  scintigra- 
phy may  be  helpful  in  establishing  the  diagno- 
sis as  well  as  in  localizing  the  lesion.  Removal  of 
the  entire  nidus  is  important  in  order  to  relieve 
symptoms  associated  with  this  abnormality.1 

REFERENCES 

1.  Swee  RG,  McLeod  RA,  Beabout  JW.  Osteoid  os- 
teoma: detection,  diagnosis,  localization.  Radiol- 
ogy 1979;117:130-138. 


Dr  Neitzschman  is  Associate  Professor  of 
Radiology  Orthopaedics  and  Nuclear  Medicine 
at  Louisiana  State  University 
Health  Sciences  Center 
in  New  Orleans,  Louisiana. 

Dr  Wilson  is  Assistant  Professor  of  Orthopedics 
at  Louisiana  State  University 
Health  Sciences  Center 
in  New  Orleans,  Louisiana. 


224  J La  State  Med  Soc  VOL  152  May  2000 


Histo  ' f Me 


A Grits  Mill: 

The  Story  of  Field  Memorial  Hospital 

Michael  M.  Sawyer,  MD 


This  is  the  second  of  a series  of  award  winning  Medi- 
cal Historical  articles  presented  at  the  Tulane  His- 
tory of  Medicine  Society. 


"Once  again,  Mike,  let  me  reiterate,  our  goal  is 
and  has  always  been  to  bring  the  highest  qual- 
ity medical  care  to  rural  America."  These  words 
cross  the  lips  of  Dr  Richard  Jennings  Field  Jr  as 
they  probably  have  thousands  of  times.  The  flow 
is  eloquent,  so  much  so  that  it  is  obvious  that  he 
has  not  just  said  this  or  thought  this  for  the  first 
time.  The  conviction  and  dedication  in  his  voice 
is  pronounced.  This  is  a core  statement  of  a man 
speaking  about  his  life's  work.  There  is  little  rea- 
son to  doubt  that  what  is  said  by  him  across  the 


board  is  privileged  information.  He  exudes  the 
understanding  that  he  has  lasted  through  the 
years  because  of  some  simple  axioms  by  which 
he  must  live.  Axioms  that  are  older  than  his  72 
years.  Dr  Richard  Jennings  Field  Jr  is  a well-deco- 
rated  soldier  of  the  surgical  profession.  His  na- 
tional accolades  meshed  with  his  dedication  to 
small  town  America  hinge  on  the  story  of  a fam- 
ily ideal  known  as  the  Field  Memorial  Commu- 
nity Hospital  (FMCH). 

The  Field  Memorial  Community  Hospital 
stands  as  a testament  to  the  history  of  modern 
medicine.  Its  place  is  firmly  rooted  in  the  his- 
tory of  Mississippi,  of  Tulane  Medical  School, 
and  even  of  the  surgical  history  of  the  nation.  A 
small  44-bed  hospital  located  in  the  heart  of  ru- 


J La  State  Med  Soc  VOL  152  May  2000  225 


ral  southwestern  Mississippi,  the  hospital  is  an 
unlikely  crossroads  for  so  much  in  the  history 
of  surgery 

Dr  Richard  Jennings  Field  was  one  of  nine 
children  born  to  'Papa  Sam'  Field  who  owned  a 
large  plantation  on  the  outskirts  of  Centreville, 
Mississippi.  Tapa  Sam'  had  the  main  saw  mill 
and  grits  mill  in  the  area  and  ground  the  meal 
for  everyone  in  the  area.  This  was  an  enormous 
undertaking,  and  Dr  Field  Jr  believes  this  was 
after  the  use  of  slave  labor  in  the  south.  Hence, 
Tapa  Sam'  took  on  the  task  alone  because  the 
community  needed  it.  That  work  ethic  still  swells 
in  the  family.  The  spirit  which  Tapa  Sam'  car- 
ried wove  its  way  into  the  fabric  of  future  gen- 
erations helping  to  change  the  face  of  southwest- 
ern Mississippi  overall. 

Three  doctors  arose  from  the  brood  of  nine, 
all  of  whom  went  to  the  Tulane  University 
School  of  Medicine.  Columbus  Leonious  (C.L.) 
Field  was  the  first  doctor  in  the  family.  He  had 
graduated  from  the  Tulane  School  of  Medicine 
and  had  been  trained  there  as  well.  He  returned 
home  with  the  hopes  of  bringing  some  health 
care  to  this  rural  community  because,  like  his 
father  with  the  mill  before  him,  the  community 
needed  it.  He  came  to  practice  in  Centreville  in 
1916.  His  tenure  in  Centreville  was  short,  only  4 
years,  falling  victim  to  the  hard  times  that 
plagued  the  area.  In  1920,  he  left  Centreville  and 
moved  to  the  Delta  of  Mississippi. 

C.L/s  younger  brothers,  Richard  Jennings 
Field  and  Sam  Field  attended  undergraduate  at 
Ole  Miss.  They  began  at  Ole  Miss  together  dur- 
ing the  same  year  that  C.L.  had  triumphantly 
returned  to  Centreville  and  begun  his  practice, 
1916.  Richard,  was  known  affectionately  as 
Jennings  as  he  grew  up,  and  this  name  followed 
him  into  college  and  Tulane  Medical  School. 

After  graduation  Dr  Jennings  stayed  on  at 
Tulane  to  receive  his  surgical  training  under  the 
world  famous  Dr  Rudolph  Matas.  The  stories  of 
Dr  Matas  flow  easily  out  of  Dr  Field  Jr  who 
speaks  with  obvious  homage  and  unconscious 
pride  when  reflecting  on  his  father's  relation- 
ship with  the  famous  Tulane  idol. 


Dad  was  one  of  his  favorite  residents.  I don't 
say  that  because  he  is  my  father,  but,  every 
time  when  1 was  a kid  we'd  go  to  New  Or- 
leans and  for  whatever  reason,  Dad  would 
always  go  by  and  see  Dr  Matas.  Also,  we'd 
go  down  to  Carnival  and  watch  it  from  his 
front  porch  on  St.  Charles  Ave.  So  when  I 
went  to  medical  school  and  became  presi- 
dent ofNu  Sigma  Nu,  he  was  an  honorary 
Nu  Sigma  Nu  member.  I got  to  know  him 
again  and  be  with  him  some  more  myself. 

While  Jennings  worked  in  New  Orleans  under 
Dr  Matas,  Sam  Field  took  his  surgery  training  at 
Loyd  Noland  Railroad  Hospital  in  Birmingham, 
Alabama.  This  was  considered  an  excellent  resi- 
dency program  in  those  days  and  is  now  part  of 
the  University  of  Alabama  School  of  Medicine. 
Dr  Sam  finished  in  1922  after  his  2-year  surgery 
residency  and  left  Birmingham  for  Miami, 
Florida.  In  the  same  year  Dr  Jennings  finished 
with  Dr  Matas  and  much  to  the  surprise  of  Dr 
Matas,  he  told  Dr  Matas  he  wanted  to  "come 
back  here  to  Centreville,  where  he  was  born  and 
raised".  Dr  Matas  offered  the  young  doctor  a 
place  on  staff  at  Tulane.  However  at  this  point, 
Jennings  Field  explained  to  Dr  Matas  what  drove 
him;  he  wanted  to  bring  good  medicine  to  the 
people  of  a rural  area.  This  vision  had  been  brew- 
ing since  the  community  outreach  of  his  father's 
mill. 

Dr  Jennings  Field,  known  strictly  as  "Dr 
Jennings'"  in  the  community,  practiced  General 
Surgery  for  6 years  from  1922-1928  on  Main 
Street  in  Centreville  over  the  drugstore.  The  72- 
year-old  Dr  Field  Jr  states  "I  see,  even  today, 
some  elderly  people  that  he  had  removed  their 
tonsils  or  even  appendix  in  his  office  over  the 
drugstore."  These  procedures  were  done  with 
open  drop  chloroform  by  a nurse.  "I  marvel  at 
that,  and  I don't  know  how  he  did  it.  I don't  think 
he  should  have,  but  we're  talking  about  the 
1920s."  The  more  complicated  patients  were  sent 
by  Dr  Jennings  via  train  to  Baton  Rouge  or,  pref- 
erably, New  Orleans  because  of  his  ties  to  Tulane. 
But  the  need  for  medical  care  continued  in  the 
community  and  word  spread  to  neighboring 


226  J La  State  Med  Soc  VOL  152  May  2000 


communities  that  Dr  Jennings  may  be  able  to 
help.  He  often  found  himself,  like  his  brother 
C.L.  before  him,  without  the  facilities  to  provide 
the  care  which  he  had  been  trained  to  give.  In 
1928,  Dr  Jennings  took  a major  step.  He  an- 
nounced to  his  wife  that  he  was  going  to  open  a 
hospital.  His  wife  felt  the  true  fear  that  comes 
with  such  a venture,  because  the  only  way  to 
finance  the  project  was  to  mortgage  the  house. 
He  borrowed  $50,000,  a colossal  sum  in  1928.  It 
was  time  that  the  vision  be  tested.  It  had  been  a 
difficult  practice  for  Dr  Jennings  over  the  drug- 
store, not  for  lack  of  patients  but  for  lack  of  fa- 
cilities. He  had  told  Dr  Matas  that  he  wanted  to 
bring  good  medicine,  not  just  medicine,  to  the 
people  of  his  hometown.  Dr  Jennings  learned 
from  his  elder  brother's  plight  and  the  decision 
to  build  a hospital  signified  the  dropping  of  the 
gauntlet.  The  die,  however,  had  been  cast  many 
years  before  in  a local  grits  mill. 

In  March  1928,  the  original  35-bed  Field  hos- 
pital was  built.  The  opening  of  the  hospital  was 
a grand  affair  with  the  dedication  address  given 
by  Tulane's  own  Dr  Rudolph  Matas.  Other 
speeches  given  on  that  day  were  delivered  by 
Dr  Jennings,  Dr  Sam,  and  the  Governor  of  Mis- 
sissippi. With  the  support  of  the  state  and  the 
local  community,  the  brothers  Field  built  a tre- 
mendous practice  of  both  General  Surgery  and 
Family  Practice.  The  surrounding  area  itself  was 
without  much  medical  care.  In  fact,  at  this  stage 
Baton  Rouge  was  not  very  well  developed,  so 
people  would  travel  great  distances  to  see  the 
Field  brothers.  This  is  how  the  practice  stayed 
until  the  1950s.  The  hospital  was  the  center  of 
town  and  it  was  always  very  busy.  Also,  with 
the  birth  of  the  logging  industry  as  well  as  cattle, 
the  area  was  bustling.  This  allowed  the  hospital 
to  serve  a greater  group  of  local  communities. 
As  the  state  grew  so  did  Dr  Jenning's  vision:  he 
helped  form  the  medical  community  of  the  en- 
tire state  by  becoming  the  first  president  of  the 
Mississippi  Hospital  Association. 

In  1966,  there  was  the  addition  of  a third  Field 
to  the  hospital  staff.  Dr  Richard  Jennings  Field 
Jr.  He  had  graduated  from  Centreville  High 
School  and  headed  towards  New  Orleans  and 


Tulane.  Richard  Jr,  "Dickie",  was  a member  of 
the  cheerleading  squad  of  the  mightv  Green 
Wave  while  he  studied  his  pre-medical  curricu- 
lum. He  then  was  accepted  at  Tulane  Medical 
School  and  remained  in  New  Orleans  to  take  his 
residency  training  under  the  eye  of  Dr  Alton 
Ochsner. 

As  his  father  had  been  before  him,  Richard 
Jennings  Field  Jr  was  a leader  at  Tulane  Medical 
School.  He  also  had  been  elected  the  president 
of  Nu  Sigma  Nu  medical  fraternity.  Perhaps 
more  fortuitous  was  his  election  as  the  first  presi- 
dent of  the  Tulane  Surgical  Society.  The  first 
meeting  of  the  Society  included  such  Tulane  no- 
tables as:  Dr  Field  Jr,  Dr  Alton  Ochsner,  Dr 
Michael  DeBakey,  and  Dr  Oscar  Creech.  Other 
notables  that  hang  on  the  wall  at  the  Field  Clinic 
include  a copy  of  a painting  now  hanging  in  the 
Surgery  department  at  Tulane  Medical  School 
of  Dr  Mims  Gage  (see  portrait  below),  a clinical 
professor  of  surgery  while  Dr  Field  Jr  was  a resi- 
dent. Hidden  in  the  background,  according  to 
Dr  Field  Jr,  are  two  residents  of  which  he  is  one. 
(Figure  courtesy  of  Dr  Gustavo  Colon) 


When  his  training  was  complete  under  Dr 
Ochsner,  Dr  Dick  returned  home,  hoping  to  con- 
tinue the  vision  that  his  father  had  had  nearly 
40  years  before.  Now  the  vision  expanded.  "My 


J La  State  Med  Soc  VOL  152  May  2000  227 


vision",  states  Dr  Dick,  "was  to  bring  all  the  spe- 
cialty care  we  could  to  our  rural  people".  In- 
deed the  drive  for  care  has  been  delivered. 

The  specialty  care  has  followed  and  does 
have  a role  to  play  in  this  community.  Presently, 
Dr  Richard  Jennings  Field  III  (Dr  Rich)  repre- 
sents the  next  generation  in  General  Surgery  at 
Field  Memorial.  Rich  is  also  a graduate  of 
Tulane  Medical  School  who  completed  his  resi- 
dency at  Tulane  and  Charity  hospital  in  1984  as 
well.  Also,  an  Internist,  a Pediatrician,  a Nurse 
Midwife,  a Podiatrist,  and  nearby  Family  Prac- 
titioners are  established  as  the  core  of  the  local 
health  care  network.  In  addition,  the  hospital 
pulls  in  specialists  for  short  periods.  An  Ortho- 
pedic Surgeon  comes  two  mornings  a month, 
an  Ophthalmologist  comes  two  afternoons  a 
month;  both  are  able  to  operate  at  the  FMCH 
when  they  have  local  cases.  Occasionally,  the 
hospital  is  able  to  hire  the  services  of  a Derma- 
tologist. This  is  a far  cry  from  the  original  build- 
ing in  which  the  Field  brothers  did  all  the  medi- 
cal and  administrative  work. 

In  1952,  the  original  building  had  a new  ad- 
dition. The  hospital  had  grown  to  an  88-bed  ca- 
pacity. It  was  still  attached  to  the  Field  Clinic 
that  had  been  developed  in  the  first  floor  of  the 
old  building.  Despite  serving  in  the  Navy,  Dr 
Field  Jr  managed  to  return  home  for  the  dedi- 
cation. This  also  proved  to  be  a fortuitous  deci- 
sion because  the  dedication  address  was  given 
by  Dr  Alton  Ochsner,  who  would  soon  serve  as 
mentor  to  the  young  doctor  through  his  resi- 
dency at  Tulane. 

In  1965,  the  old  hospital  was  torn  down  and 
the  new  wing  was  built  with  the  new  Field 
Clinic  erected  directly  outside  the  building.  The 
ball  that  had  been  set  in  motion  40  years  before 
now  contained  unstoppable  inertia.  The  hospi- 
tal has  also  appreciated  the  needed  inclusion 
of  administration.  In  the  1990s  another  renova- 
tion was  undertaken  allowing  for  the  business 
space  required  to  run  a hospital  and  the  hospi- 
tal assumed  its  present  role  of  a well-equipped 
and  staffed  community  hospital,  presently  with 
a 44-bed  capacity. 


Dr  Sam  passed  away  in  1965  due  to  bladder 
cancer.  Dr  Jennings  followed  in  1972  suffering  a 
CVA.  In  reflecting  on  the  work  that  has  created 
the  Field  Memorial  Community  Hospital  and  the 
vision  it  supports.  Dr  Dick  sighs  and  says,  "It 
has  been  an  interesting  missionary  sort  of  en- 
deavor, yet,  we  are  close  enough  to  New  Orleans, 
Jackson,  and  Baton  Rouge  that  we  can  enjoy  the 
pleasures  of  the  urban  activities  as  well  as  to  be 
on  staff  of  Tulane,  LSU,  and  the  University  of 
Mississippi  Medical  Schools."  Dr  Dick  readily 
admits  the  importance  of  having  good  rapport 
with  the  major  medical  centers.  This  has  led  to  a 
long  time  commitment  to  Tulane  Medical  School. 
Not  only  does  the  rural  hospital  serve  almost  as 
a satellite  for  the  medical  center,  by  sending  the 
more  complex  cases  to  the  appropriate  places, 
but  it  allows  a quick  resource  for  the  hospital 
staff  to  use  the  information  available  at  a major 
medical  center.  Also,  the  Field  Hospital  has 
stayed  in  tune  with  the  changes  in  medical  edu- 
cation by  offering  a rotation  as  a fourth  year  elec- 
tive, normally  in  General  Surgery.  This  shows 
the  students  how  much  can  be  possible  in  rural 
America.  "I  think  that  the  medical  schools  need 
to  look  at  community  hospitals  to  use  them  as 
much  as  they  can,  and  the  community  hospitals 
need  to  look  at  the  medical  schools  to  get  their 
students  because  they  elevate  their  level  of  prac- 
tice." 

So  the  story  is  one  of  triumph,  although  Dr 
Dick  will  be  the  first  to  speak  of  the  struggle  that 
continually  haunts  the  hospital  to  maintain  its 
integrity.  But  the  Fields  are  committed  to 
Centre ville  and  to  medicine  in  rural  America. 

He  notes  an  extra  level  of  intensity  befalls 
any  physician  when  forced  to  treat  those  he  is 
close  to.  While  a blessing,  this  can  also  be  a tre- 
mendous responsibility.  "My  patients,  well  I'm 
kin  to  most  of  them,  and  I went  to  school  with 
the  rest  of  them,  and  they  expect  me  to  get  them 
well."  Dr  Dick  would  be  the  first  to  say  this  is 
not  a major  problem  but  it  can  be  taxing. 

The  simple  things  are  the  focus  of  what  the 
Field  family  teaches.  Dr  Dick  uses  a classic  icon 
of  medicine  to  pass  this  point  along.  The  paint- 


228  J La  State  Med  Soc  VOL  152  May  2000 


ing  entitled  The  Doctor  by  Sir  Luke  Fildes  hangs 
quietly  on  the  wall  of  his  office,  as  it  hung  in  his 
father's  office  before.  He  reflects: 

This  doctor  I see  sitting  there  with  the  little 
girl,  you  can  see  the  father  in  the  back- 
ground. This  doctor  sits  there  with  a little 
cup  of  perhaps  homemade  cough  syrup.  This 
is  all  he  has,  he  has  no  hospital,  and  he  has 
nothing  to  treat  this  child's  disease.  Yet,  a 
curiously  strange  and  mysterious  situation. 

That  father  had  more  trust  in  that  doctor 
than  our  patients  do  in  us  today.  Now  that 
is  a sobering  thought.  When  and  how  did 
we  lose  this  trust,  I do  not  know.  The  things 
that  this  doctor  in  the  painting  has  that  we 
may  have  lost  are  concern,  and  love,  and 
care,  and  appreciation. 

With  a stern  grip  on  medical  ideals  of  the  past 
and  a keen  insight  into  the  changes  in  the  fu- 
ture, the  Field  Memorial  Community  Hospital 
can  continue  its  mission.  The  work  and  dedica- 
tion of  the  Field  family  is  a credit  to  the  commu- 
nity and  to  the  development  of  medicine  in  the 
South. 

The  legend  in  no  way  ends  with  Dr  Dick. 
His  personal  tutelage  in  life  is  accompanied  per- 
fectly with  the  technical  study  driven  by  Dr  Rich. 
Humbly,  he  lets  his  father  preach  the  wisdom 
while  he  stays  adept  at  the  most  modern  surgi- 
cal skills.  With  respectful  sarcasm  he  plays 
devil's  advocate  to  his  father.  Yet,  he  carries  his 
father's  eyes,  probably  the  eyes  of  three  genera- 
tions before  him.  In  these  eyes  one  can  see  that 
the  lessons  have  been  well  taught,  and  under 
his  auspice,  the  lessons  will  not  be  lost  in  future 
generations. 


GACHASSIN 

L A W • F I R M 

Devoted  to  the  Representation  and  Counseling 
of  the  Health  Care  Industry 

The  Gachassin  Law  Firm  provides  quality,  cost- 
effective  legal  services  to  diverse  clients  in  the 
health  care  industry.  Our  attorneys  are  experienced 
in  transactional  and  corporate  matters,  managed 
care  contracting  and  issues,  physician  practice 
management  organizations,  Medicare  and 
Medicaid  reimbursement  issues,  fraud  and  abuse 
and  Stark  compliance,  regulatory  and  legislative 
issues,  medical  malpractice  defense  and  risk 
management. 

Nicholas  Gachassin,  Jr.  Nicholas  Gachassin,  III 

Susan  Severance  Richard  MacMillan 

T.  Rose  Young  Thomas  H.  Morrow 

Julie  Hoffpauir 

1026  St.  John  Street,  Lafayette,  Louisiana  70501 
Telephone:  (337)  235-4576  Fax:  (337)  235-5003 

E-Mail:  gh@gachassin.com 
www.gachassin.com 


Dr  Sawyer  is  presently  in  his  internship  year  of 
a General  Surgery  residency  at  the 
University  of  California,  Davis-East  Bay,  California. 


J La  State  Med  Soc  VOL  152  May  2000  229 


LSMS  Alliance 


Of  Course  Change  is  a Risk  . . . 


Mrs  Nenita  Roy 


Change  may  be  risky,  but  it  is  also  un- 
avoidable. And  it  can  actually  be  fun  and 
exciting.  Even  thrilling.  We've  all  heard 
so  much  lately  of  that  modern  mantra  for  the 
timid,  the  "comfort  zone",  that  safe-sounding 
spot,  that  haven  of  sameness  and  security.  How 
tempting  it  must  seem  to  stay  right  there.  Com- 
fort. Hard  to  resist.  But  how  effortful,  how  scary 
even,  to  depart  it.  The  good  news,  to  reiterate, 
is  that  life  forces  upon  us  that  very  thing  that 
enables  us  to  grow  and  improve:  change. 

Our  own  Alliance  has  been  going  along  more 
or  less  in  the  same  way  for  decades.  "Things 
we  always  do",  LSMSA  President  Karen  Depp 
recently  termed  it.  Habitual.  Comfortable.  By  the 
book.  No  need  to  change  anything  but  names 


and  faces  and  addresses.  So  what's  wrong  with 
that?  So  why  do  we  need  to  make  real  changes 
now?  Simple,  really.  We  must  progress  or  per- 
ish. An  example:  We  needed  to  move  our  an- 
nual convention  from  April  to  October  and  hold 
it  in  Baton  Rouge  in  order  to  enhance  interest 
and  increase  attendance  for  both  our  and  the 
LSMS  meetings.  Another  example  of  a major 
need  is  somewhat  less  clear  or  simple. 

Entering  this  new  millenium  we  possess 
highly  advanced  technology  that  will  serve  us 
well  if  we  use  it  wisely.  Thus,  the  creation  of  our 
LSMSA  website.  Using  this  medium  we  can 
greatly  improve  our  communication,  record 
keeping,  political  influence,  awareness  of  perti- 
nent goings-on  and  much  more.  And  at  nearly 


230  J La  State  Med  Soc  VOL  152  May  2000 


the  speed  of  light.  I urge  everyone  to  please  visit 
the  site  at  http://www.lsms.org/alliance/lsmsa.htmL 

There  you  will  see  names  of  officers  and  com- 
mittee chairpersons,  and  various  other  resources 
that  will  afford  us  a direct  link  to  our  other  par- 
ish chapters  and  members.  Oh  yes,  you  can  con- 
sult our  calendar  of  events  or  even  print  an  ex- 
pense voucher  from  this  site. 

A new  position  has  been  created,  that  of  the 
Internet  Communication  Chair.  Each  parish  will 
be  expected  to  have  one  so  he  or  she  can  access 
the  website  and  participate  in  the  new  and  ex- 
citing ways  that  Karen  Depp  alluded  to.  Does 
all  this  sound  a little  scary?  Uncomfortable?  Feel 
yourself  being  tempted  to  claim  computer  illit- 
eracy, or  admit  that  you  don't  even  own  a com- 
puter? 

Feel  not  alone.  Numerous  of  you  may  be 
computer  whizzes  but  others  of  us  are  or  have 
been  of  that  "other"  status.  For  me,  I was  both 
electronically  retarded  and  computerless  until 
a few  years  ago.  I don't  even  remember  what 
moved  me  to  get  one  of  these  complex  gadgets, 
but  I perservered  and  it  became  more  and  more 
interesting  and  enjoyable  to  use.  Fortunately, 
great  know-how  is  not  required  to  develop  email 
proficiency,  or  "browse  the  web",  or  search  end- 
less places  or  do  other  really  neat  things  we  never 
thought  possible.  Today's  computers  are  indeed 
consumer  friendly  and  inexpensive  to  acquire. 

I recently  bought  my  second  home  computer, 
in  part  to  relieve  the  computer  congestion  within 
my  family.  I paid  only  about  $200  for  this  new 
unit  which  included  a large  screen  and  far  more 
speed  and  goodies  than  my  much  more  expen- 
sive older  model  possessed.  I was  able  to  take 
advantage  of  available  rebates  and  other  mark- 
downs  and  requirements  in  order  to  buy  the  new 
equipment  at  such  a low  price.  And  prices  con- 
tinue to  decline  as  quality  improves. 

Karen  Depp  will  have  a session  during  our 
annual  meeting  in  October  to  discuss  this  new 
method  of  communication.  We  earnestly  hope 
that  you  and  certainly  your  appointed  internet 
communication  chair  will  attend  this  meeting.  I 
also  plan  to  have  a rap  session  where  everyone 


is  encouraged  to  speak  out  and  freely  express 
their  thoughts  and  feelings  about  this  and  any 
other  matters.  We  need  to  know  how  you  feel 
about  these  and  other  changes,  and  how  we  can 
improve  the  relationship  between  the  state  and 
the  parish  alliances.  Your  honest  input  is  essen- 
tial to  our  success. 

Remember  this.  If  I can  go  from  where  I was 
to  where  I am,  so  can  you.  Not  that  "my  am"  is 
all  that  far  advanced,  but  it  is  good  enough  to 
do  most  of  the  things  I want  or  need  on  the  com- 
puter. And  for  me  who  can't  even  ride  a bicycle, 
try  as  I might.  Now,  THAT  should  give  you  a 
boost.  Why,  in  no  time  you  can  be  well  ahead  of 
me.  And  it  really  is  worth  it.  Believe  me. 

I look  forward  to  being  with  you  in  Baton 
Rouge  this  October.  It  will  be  fun  seeing  every- 
one after  such  a long  time.  We  have  lots  of  catch- 
ing up  to  do.  We  also  have  a lot  of  work  to  get 
done.  And  we've  got  to  count  on  each  other  to 
do  it  for  the  sake  of  our  spouses,  our  Alliance 
and  ourselves.  Our  future  is  now,  as  the  saying 
goes,  and  we  are  it. 


Mrs  Roy  is  President-Elect  of  the 
Louisiana  State  Medical  Society  Alliance. 


J La  State  Med  Soc  VOL  152  May  2000  231 


Cardiovascular  Disease 

in  Louisiana 

It  Is  More  Than  Just  the  Heart 
for  the  American  Heart  Association: 
New  Interventions  in  the  Vascular  Tree 

Frank  M.  Sheridan,  MD 


Over  the  many  years  that  the  Journal  of 
the  Louisiana  State  Medical  Society  has 
so  kindly  invited  Louisiana  volunteers 
of  the  American  Heart  Association  to  compose 
an  annual  special  issue,  we  have  clearly  con- 
centrated our  efforts  on  updating  the  medical 
community  of  our  state  on  heart  disease.  That 
probably  seems  natural  enough.  However,  those 
of  us  who  work  in  or  with  the  American  Heart 
Association  know  that  the  organization  repre- 
sents the  promotion  of  research  and  education 
efforts  on  all  forms  of  cardiovascular  disease, 
not  just  those  associated  with  the  heart.  To  com- 
bat this  understandable  misconception,  a few 
years  back  the  slogan  under  the  American  Heart 
Association  logo  was  changed  to  say  "Fighting 
Heart  Disease  and  Stroke".  Just  last  year  a new 
division  of  the  American  Heart  Association  was 
initiated  called  the  American  Stroke  Associa- 
tion. But  even  these  efforts  do  not  completely 
define  the  mission,  as  the  association  is  dedi- 
cated to  funding  research  and  promulgating 


information  on  all  forms  of  vascular  disease.  The 
organization's  efforts  range  widely,  from  at- 
tempts to  reduce  hypertension  and  tobacco  use, 
to  funding  of  clinical  and  basic  science  on  en- 
dothelial function  in  the  arteries  and  veins  of  all 
tissue,  to  promoting  healthy  menus  for  school 
children,  to  advocating  increased  funding  for  all 
science  through  the  National  Institute  of  Health. 
Indeed,  it  should  more  appropriately  be  called 
the  American  "science  of  blood  vessels  and  re- 
lated organs"  association,  but  that  loses  a cer- 
tain ring  and  lacks  name  recognition. 

We  have  tended  in  these  special  editions  to 
concentrate  on  coronary  artery  disease,  as  it  is 
so  prevalent.  This  issue  is  dedicated  primarily 
to  exploring  non-heart  topics,  with  one  addi- 
tional article  exploring  a "non-coronary  artery" 
heart  interventional  technique.  Over  the  past 
decade  incredible  strides  have  been  made  in  per- 
forming life-,  brain-,  and  limb-saving  interven- 
tions which  formerly  could  only  be  accom- 
plished via  major  surgery,  if  at  all.  In  the  follow- 


232  J La  State  Med  Soc  VOL  152  May  2000 


Cardiovascular  Disease 
in  Louisiana 


ing  five  articles,  recently  developed 
interventional  therapies  will  be  reviewed  which 
address  stroke,  renal  disease,  aortic  disease,  and 
cardiac  arrhythmias. 

Nearly  one  million  Americans  die  of  some 
form  of  cardiovascular  disease  every  year.  That's 
a death  every  33  seconds.  This  represents  over 
41%  of  all  deaths  in  our  country,  and  Louisiana 
has  one  of  the  highest  rates  in  the  nation,  year 
after  year.  Over  the  twentieth  century,  cardio- 
vascular disease  has  been  the  number  one  killer 
of  Americans  every  year  except  in  1918  (when 
the  world  was  hit  by  a massive  influenza  epi- 
demic). Of  course,  mortality  statistics  do  not  tell 
the  whole  story.  Of  the  current  US  population  of 
about  268  million,  almost  60  million  people  have 
some  form  of  cardiovascular  disease,  and  it 
ranks  first  among  all  disease  categories  in  num- 
ber of  hospital  discharges.  It  is  estimated  that 
the  annual  monetary  cost  of  cardiovascular  dis- 
ease to  our  nation  is  currently  about  $327  bil- 
lion.1 

One  of  the  most  devastating  of  these  diseases 
is  stroke,  which  strikes  about  600,000  Americans 
and  kills  about  160,000  of  us  each  year.1 
Cerebrovascular  accidents  are  the  leading  cause 
of  serious,  long-term  disability  in  the  United 
States  each  year.  Two  articles  in  this  series  review 
new  aggressive  therapies  to  treat  and  attempt 
to  prevent  stroke.  The  first,  written  by  the 
Chairman  of  Neurology  at  LSUHSC  - 
Shreveport,  Dr  Roger  Kelley,  describes  how  the 
therapy  which  has  been  so  successful  in  saving 
lives  and  myocardium  during  heart  attacks, 
thrombolysis,  can  in  certain  cases  now  be 
applied  to  stroke  victims.  While  the  practice  of 
reperfusion  therapy  of  the  brain  during  the  acute 
event  is  in  its  infancy,  it  holds  great  promise  for 
future  developments.  An  accompanying  review 
provides  a description  of  the  recent  development 
of  interventional  percutaneous  techniques  which 
have  been  used  worldwide  to  treat  carotid 
disease  in  an  attempt  to  prevent  strokes.  Dr 
Henry  Hanley,  Chief  of  Cardiology  at  LSUHSC- 
S,  Dr  Edwin  Rivera,  interventional  radiologist, 
and  I discuss  carotid  stenting  and  a model  for 
optimal  program  development.  As  experience 


is  gained  by  teams  of  investigators  and 
encouraging  results  are  published,  indications 
for  this  new  procedure  are  broadening  and  offer 
hope  to  the  many  patients  who  are  considered 
at  high  risk  for  carotid  endarterectomy. 

The  transvenous  placement  of  permanent 
pacemakers  requiring  only  minimal  local  dissec- 
tion has  been  the  established  therapy  for 
bradyarrhythmias  for  some  time  (145,000  per 
year).1  After  several  false  starts,  investigators  and 
clinicians  over  the  past  decade  have  rapidly  de- 
veloped new  algorithms  for  the  treatment  of 
tachyarrhythmias  which  involve  aggressive  per- 
cutaneous catheter  techniques.  Dr  Pratap 
Reddy,  Director  of  Electophysiology  at  LSUHSC- 
S,  along  with  two  of  his  senior  fellows,  Drs 
Neeraj  Tandon  and  Chuck  Monier,  review  the 
current  indications  for  and  describe  the  innova- 
tive percutaneous  treatment  of  supraventricu- 
lar tachyarrhythmias,  and  explain  how  these 
have  expanded  to  include  some  ventricular 
tachycardias. 

Mortality  is  estimated  at  44,000  deaths  a year 
due  to  peripheral  artery  disease.1  In  the  last  two 
articles  of  this  series  Dr  Rivera  and  I,  along  with 
senior  cardiology  fellow  Dr  Abochamh,  describe 
innovations  in  interventions  for  disease  in  a 
couple  of  important  peripheral  arteries,  the  aorta 
and  the  renals.  Aneurysms,  dissections,  and 
stenoses  of  large  peripheral  arteries  previously 
have  been  treated  with  major  surgery,  sometimes 
with  significant  risk  as  many  of  these  patients 
are  old  or  ill.  Now  techniques  which  have  for 
over  two  decades  been  applied  to  coronary  ar- 
teries are  being  used  successfully  to  treat  these 
vessels.  The  ability  to  avoid  general  anesthesia 
and  shorten  procedure  times  via  interventional 
techniques  may  aid  many  patients  who  were  not 
previously  considered  eligible  for  definitive 
treatment. 

It  is  hoped  that  our  departure  from  a con- 
centration on  the  heart  will  be  of  interest,  and 
that  these  articles  prove  educational  and  useful 
to  the  reader.  We  thank  the  Journal  for  this  op- 
portunity to  serve  the  medical  community.  We 
also  hope  that  you  will  support  the  activities  of 
the  American  Heart  Association  in  your  com- 


J La  State  Med  Soc  VOL  152  May  2000  233 


Cardiovascular  Disease 
in  Louisiana 


munity  in  its  broad  mission  to  decrease  death 
and  disability  from  all  forms  of  cardio-vascular 
disease. 

REFERENCES 

1.  American  Heart  Association.  2000  Heart  and  Stoke 
Statistical  Update:  National  Center.  Dallas,  Tex: 
American  Heart  Association;  2000. 


Dr  Sheridan  is  an  interventional  cardiologist  at 
Louisiana  State  University  Health  Sciences  Center  in 
Shreveport , Louisiana , serves  on  the  faculty  at  the  LSU 
School  of  Medicine  as  a Professor  of  Medicine,  and  is 
also  a member  of  the  Board  of  Directors  of  the  Southeast 
Affiliate  of  the  American  Heart  Association. 


Joey  & Vita  DiMaggio, 
proprietors  of  the  Rose 
Garden  of  Jefferson, 
enjoy  their  commercial 
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and  tke  kigkest  standards  of  design  and  con- 
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234  J La  State  Med  Soc  VOL  152  May  2000 


Cardiovascular  Disease 
in  Louisiana 


Carotid  Stenting: 

A Technology  in  Evolution 

Henry  G.  Hanley,  MD;  Frank  M.  Sheridan,  MD;  and  Edwin  Rivera,  MD 


Interest  in  stenting  lesions  involving  the  carotid  artery  bifurcation  has  grown  during  the 
past  10  years.  Techniques  first  utilized  by  Theron  and  Mathias  in  Europe  and  Roubin  and 
colleagues  in  the  United  States  have  evolved  to  where  the  technique  has  been  extensively 
refined  and  its  safety  and  efficacy  firmly  established.  The  only  prospective  randomized 
study  comparing  carotid  stenting  with  carotid  endarterectomy,  CAVATAS  (Carotid  and 
Vertebral  Artery  Transluminal  Angioplasty  Stenting),  showed  similar  safety  profiles  and 
long-term  results  for  both  techniques.  A large  scale  NIH-sponsored  trial  is  now  in  progress, 
CREST  (Carotid  Revascularization  Endarterectomy  versus  Stent  Trial),  but  the  results  are 
5-6  years  away.  In  the  interim,  one  approach  toward  instituting  a carotid  stent  program  is 
described. 


During  the  past  10  years  there  has  been 
an  explosive  growth  in  the  use  of  vas- 
cular stents,  both  in  the  coronary  and 
peripheral  circulations.  As  the  experience  of  the 
operators  increased  and  the  techniques  and 
equipment  improved,  interest  developed  in  the 
possible  application  of  these  techniques  to 
stenoses  involving  the  carotid  bifurcation.  In  the 
early  1990s  pioneering  efforts  by  Theron1  and 
Mathias2  in  Europe  demonstrated  that  stenotic 
lesions  of  the  carotid  bifurcation  could  be  safely 
approached  using  interventional  techniques. 
Then,  in  March  1994  at  the  University  of  Ala- 
bama at  Birmingham,  a multidisciplinary  group 
composed  of  Jiri  J.  Vitek,  MD,  PhD  (Neurora- 
diology), Gary  S.  Roubin,  MD,  PhD  (Cardiol- 
ogy and  Radiology),  Sriram  S.  Iyer,  MD  (Cardi- 
ology), and  Jay  Yadav,  MD  (Neurology)  began 


electively  stenting  carotid  bifurcation  lesions  and 
reported  their  results  in  1995. 3 Because  of  their 
favorable  results,  interest  in  the  technique  con- 
tinued to  spread,  such  that  currently  there  are 
several  groups  throughout  the  country  who  have 
considerable  experience  in  elective  carotid 
stenting.  It  should  be  recognized  that  lesions  of 
the  carotid  bifurcation  are  friable,  complications 
from  the  technique  can  be  catastrophic,  and  that 
carotid  endarterectomy  has  an  established  place 
in  the  current  treatment  of  these  lesions.  There- 
fore, appropriate  training,  preparation,  and  cau- 
tion should  be  utilized  in  applying  this  new  tech- 
nique. In  order  to  understand  where  carotid 
stenting  is  of  value,  it  is  necessary  to  briefly  re- 
view the  natural  history  of  carotid  occlusive  dis- 
ease and  the  results  of  carotid  endarterectomy. 


J La  State  Med  Soc  VOL  152  May  2000  235 


Cardiovascular  Disease 
in  Louisiana 


INDICATIONS  FOR 
CAROTID  ENDARTERECTOMY 

Symptomatic  Patients 

Three  prospective  randomized  trials  have  been 
completed  in  patients  with  cerebrovascular 
symptoms:  NASCET  (North  American  Symp- 
tomatic Carotid  Endarterectomy  Trial  Collabo- 
rators),6 ECST  (European  Carotid  Surgery 
Trialist  Collaborative  Group),7  and  a Veterans 
Administration  collaborative  study.8  These  stud- 
ies demonstrated  that  symptomatic  patients 
with  more  than  60%  to  70%  reduction  in  diam- 
eter of  the  carotid  artery  are  at  high  risk  of  stroke 
(26%)  when  treated  with  antiplatelet  therapy 
alone,  and  that  treatment  with  carotid  endarter- 
ectomy and  aspirin  significantly  reduces  this  risk 
(to  9%)  providing  the  surgery  can  be  performed 
with  a periprocedural  stroke  or  death  rate  of  6% 
or  less.  If  symptomatic  patients  have  < 30% 
stenosis,  medical  therapy  is  preferable  to  sur- 
gery. One  of  these  studies  demonstrated  that 
women  have  much  less,  if  any,  benefit  from  ca- 
rotid endarterectomy.  It  should  be  noted,  how- 
ever, that  high-risk  patients  were  excluded  from 
these  trials,  and,  despite  this,  the  overall 
perioperative  complication  rate  from  carotid 
endarterectomy  was  26.2%  in  the  NASCET  trial 
and  19.3%  in  the  ECST.  This  emphasizes  the  need 
to  look  for  alternative  approaches  to  the  treat- 
ment of  carotid  stenosis,  particularly  in  patients 
who  are  at  high  risk  for  carotid  endarterectomy. 

Asymptomatic  Patients 

The  ACAS  (Asymptomatic  Carotid  Atheroscle- 
rosis Study)  study9  looked  at  the  role  of  carotid 
endarterectomy  compared  with  medical  therapy 
in  asymptomatic  patients  with  > 60%  carotid 
stenosis.  It  is  notable  that  in  this  trial  the  surgi- 
cal group  had  only  a 2.3%  perioperative  risk  of 
stroke  or  death.  The  results  of  this  trial  showed 
a lower  incidence  of  ipsilateral  stroke  at  5 years 
in  the  group  who  received  endarterectomy  (4.7% 
and  9.4%).  Women  again  received  less  benefit 
from  surgery. 

The  ACAS  trial  did  not  analyze  their  results 
relative  to  the  severity  of  the  carotid  stenosis. 


However,  the  ECST  trial  did  evaluate  this  in  their 
asymptomatic  patients.  In  patients  who  had 
asypmtomatic  carotid  stenosis  of  < 80%,  the 
stroke  rate  with  medical  therapy  only  was  < 2% 
(3  years).  In  the  80%  to  89%  internal  carotid  ar- 
tery stenosis  group  the  stroke  rate  was  9.8%  with 
medical  therapy  and  in  the  90%  to  99%  group  it 
was  14.4%.  The  American  Heart  Association 
Guidelines  for  Carotid  Endarterectomy  (1998)10 
recommend  surgery  for  asymptomatic  patients 
with  stenotic  lesions  of  > 60%  diameter  reduc- 
tion if  the  surgical  risk  is  < 3%  and  life  expect- 
ancy is  at  least  5 years.  Because  of  the  low  op- 
erative mortality  / morbidity  rate  in  the  ACAS 
trial,  these  results  may  not  be  extrapolated  to 
other  settings,  and,  because  in  the  ECST  trial  the 
stroke  rate  with  medical  treatment  of  stenosis  of 
< 80%  was  very  low,  some  physicians  believe 
surgery  should  be  delayed  until  the  severity  of 
the  asymptomatic  lesion  approaches  80%. 

RESULTS  OF  CAROTID  STENTING 

Most  of  the  available  data  on  carotid  stenting 
are  in  the  form  of  registries.  One  of  the  largest 
databases  was  reported  by  Roubin  et  al  from  the 
University  of  Alabama  at  Birmingham  and 
Lenox  Hill  Heart  and  Vascular  Institute.11  They 
reported  on  482  patients  with  stenting  of  569 
vessels.  The  procedure-related  mortality  was 
0.9%  (4  patients)  and  the  total  30-day  mortality 
was  1.7%.  There  were  two  major  disabling 
strokes  related  to  the  procedure  and  two  others 
not  related  to  the  procedure  but  occurring  within 
30  days.  There  was  a 5.1%  incidence  of  minor 
non-disabling  strokes  that  persisted  more  than 
24  hours  but  resolved  within  30  days.  Restenosis 
that  required  repeat  intervention  occurred  in 
only  2.7%  of  this  patient  population.  Outcome 
data  on  the  first  225  patients  (266  stented  ves- 
sels) at  13  + 9 months  found  no  major  strokes,  4 
minor  strokes,  and  one  cerebral  hemorrhage  re- 
mote from  the  area  supplied  by  the  stented  ar- 
tery. While  these  results  are  registry  data,  other 
groups  have  reported  similar  findings,12  and  the 
results  suggest  that  carotid  stenting,  performed 
by  selected,  experienced  interventional  teams 


236  J La  State  Med  Soc  VOL  152  May  2000 


Cardiovascular  Disease 
in  Louisiana 


can  be  performed  with  outcomes  and  a safety 
profile  that  compares  very  favorably  to  the 
NASCET  data  for  carotid  endarterectomy. 

Registries  do  not  substitute  for  a prospective 
randomized  trial,  however.  One  such  trial, 
CAVATAS4  (Carotid  and  Vertebral  Transluminal 
Angioplasty  Stenting)  was  recently  completed 
and  another,  larger  NIH-sponsored  trial  is  now 
in  progress,  CREST5  (Carotid  Revascularization 
Endarterectomy  Versus  Stent  Trial). 

The  CAVATAS  trial  was  conducted  in  Great 
Britain  by  teams  composed  of  neurologists,  ra- 
diologists, and  vascular  surgeons  at  large  re- 
gional centers.  The  inclusion  criteria  were  broad 
and  included  high-risk  patients.  The  radiologists 
were  not  experienced  in  carotid  stenting  and  the 
stents  and  techniques  used  are  now  outdated, 
while  the  vascular  surgeons  were  experienced 
in  carotid  endarterectomy.  Nonetheless,  the  out- 
comes in  the  randomized  surgical  compared  to 
stenting  groups  were  similar  and  statistically  not 
different.  The  incidence  of  major  stroke  and 
death  was  approximately  5%  for  both  the  stent 
and  endarterectomy  groups.  The  incidence  of  all 
strokes  was  also  similar  (11%),  and  follow-up 
events  were  not  significantly  different. 

The  CREST  trial  is  an  NIH-sponsored,  pro- 
spective, randomized  trial  of  endarterectomy 
compared  to  stenting  in  patients  with  symptom- 
atic stenosis  of  a carotid  artery  with  >50%  lumi- 
nal diameter  narrowing.  Enrollment  has  recently 
begun  and  is  planned  for  2500  patients.  Unlike 
previous  endarterectomy  trials,  a key  point  in 
the  quality  of  this  study  is  that  there  will  be  an 
independent  neurological  assessment  of  both 
surgical  and  stent  patients.  The  study  will  in- 
volve credentialing  of  stent  operators  on  each 
new  device  before  it  can  be  used.  The  endpoints 
will  be  incidence  of  death,  stroke  or  myocardial 
infarction  at  30  days,  and  incidence  of  ipsilat- 
eral  stroke  at  4 years.  This  study  has  been  care- 
fully planned  and  is  expected  to  provide  defini- 
tive answers  to  many  of  the  questions  that  re- 
main, but  the  final  results  will  not  be  available 
for  the  next  5-6  years. 


FUTURE  DIRECTIONS 

Until  then,  assuming  that  this  procedure  is  a 
valuable  addition  to  the  treatment  of  carotid 
stenosis,  as  the  current  literature  indicates,  it 
would  be  unfortunate  if  it  were  not  available  to 
the  patients  who  might  benefit  most.  These  are 
patients  who  have  significant  lesions  and  who 
would  be  at  increased  risk  for  carotid  endarter- 
ectomy but  who  would  likely  be  at  less  risk  for 
carotid  stenting.  Included  are  patients  with  neck 
radiation,  radical  neck  dissections,  or  discrete 
lesions  of  the  common  carotid  or  distal  internal 
carotid,  all  of  which  create  a much  more  diffi- 
cult surgical  approach.  In  particular,  patients 
with  serious  medical  conditions  favor  a less  in- 
vasive approach  (unstable  angina  pectoris,  re- 
cent myocardial  infarction,  severe  coronary  ar- 
tery disease,  congestive  heart  failure,  severe  hy- 
pertension, peripheral  vascular  disease,  age  >70 
years,  severe  obesity,  uncontrolled  diabetes).  In 
addition,  previous  studies  have  identified  con- 
tralateral occlusion,  recent  CVA,  and  restenosis 
after  CEA  as  significantly  increasing  the  risk  of 
a surgical  approach.  If  the  patient  is  neurologi- 
cally  unstable,  carotid  stenting  may  offer  a less 
invasive  alternative  to  carotid  endarterectomy 
(which  usually  necessitates  general  anesthesia). 
Finally,  there  are,  of  course,  anatomical/ 
angiographic  considerations  that  may  make  one 
technique  more  desirable  than  the  other.  The 
higher  the  risk  to  the  patient  for  endarterectomy, 
in  general,  the  more  the  patient  may  benefit  from 
carotid  stenting.  It  should  be  cautioned  that  se- 
lecting only  high-risk  patients  for  the  initial  ex- 
perience of  a new  program  may  be  detrimental 
and  result  in  the  cancellation  of  the  program 
before  the  "learning  curve"  is  passed. 

Any  carotid  stenting  program  should  involve 
a team  of  specialists.  The  collaboration  of  Car- 
diology, Interventional  or  Neuroradiology,  Neu- 
rology, Neurosurgery,  and  Vascular  Surgery 
adds  expertise  to  this  truly  interdisciplinary 
treatment.  Irrespective  of  whether  the  procedure 
is  initiated  at  a University  Affiliated  Academic 
Medical  Center  or  in  the  private  medical  com- 
munity, a 100%  registry  follow-up  on  all  patients 


J La  State  Med  Soc  VOL  152  May  2000  237 


Cardiovascular  Disease 
in  Louisiana 


should  be  instituted  at  the  start  of  the  program. 
Carotid  stenting  consists  of  the  off-label  use  of 
an  approved  device  and  any  informed  consent 
should  reflect  this.  Approval  of  the  appropriate 
committees  (FDA/IRB  or  Credentials  commit- 
tee) should  be  obtained  prior  to  initiating  a pro- 
gram. 

It  has  been  established  that  a learning  curve 
exists  in  the  development  of  a carotid  stent  pro- 
gram. Thus,  complications  are  more  likely  dur- 
ing the  inception  of  the  program  until  a critical 
amount  of  knowledge  and  experience  is  accu- 
mulated. We  would  recommend  that  all  mem- 
bers of  the  team  (whether  professional  or  tech- 
nical) attend  a course  to  obtain  both  didactic  and 
live-case  experience  with  the  technique  prior  to 
proceeding.  Finally,  obtaining  a proctor  with 
extensive  experience  to  proctor  and  guide  the 
initial  cases  is  invaluable. 

SUMMARY 

During  the  past  10  years,  the  technology  of  ca- 
rotid stenting  has  evolved  rapidly.  Though  only 
one  head-to-head  comparison  with  carotid  en- 
darterectomy has  been  performed  (demonstrat- 
ing comparable  results),  several  patient  care  reg- 
istries have  demonstrated  that  the  procedure  has 
favorable  safety  and  outcome  results  when  com- 
pared to  carotid  endarterectomy.  Recently,  an 
NIH-sponsored  study  has  begun  (the  CREST 
trial)  to  compare  the  safety  and  efficacy  of  these 
procedures.  Unfortunately,  the  results  will  not 
be  available  for  another  5-6  years.  During  this 
time  available  data  suggest  that  a careful, 
planned  approach  to  carotid  stenting  may  be 
warranted,  in  order  to  (1)  safely  get  over  the 
learning  curve;  (2)  participate  in  randomized 
trials;  and  (3)  provide  optimum  care  to  patients 
who  would  be  at  high-risk  for  carotid  endarter- 
ectomy but  not  for  carotid  stenting. 

REFERENCES 

1 .  Theron  J,  Raymond  J,  Casisco  A,  et  al.  Percutaneous 
angioplasty  of  atherosclerotic  and  postsurgical 
stenosis  of  carotid  arteries.  AJNR  Am  J Neuroradiol 
1987;  8:494-500. 


2.  Mathias  K.  Catheter  treatment  of  arterial  occlusive 
disease  of  supraaortic  vessels.  Radiologe  1987; 
27:547-554. 

3.  Yadov  SS,  Roubin  GS,  Iyer  SS,  et  al.  Application  of 
lessons  learned  from  cardiac  interventional 
techniques  to  carotid  angioplasty.  J Am  Coll  Cardiol 
1995:380A. 

4.  Moses  fW,  Roubin  GS,  Iyer  SS,  et  al.  Advanced 
Endovascular  Therapies  - 1999.  New  York  Meeting, 
June  2-4,  1999,  Manual  73. 

5.  Hobson  RW  II,  Brott  T,  Ferguson  R,  et  al.  CREST: 
Carotid  revascularization  endarterectomy  versus 
stent  trial  (editorial).  Cardiovasc  Surg  1997;5:457- 
458. 

6.  North  American  Symptomatic  Carotid  Endar- 
terectomy Trial  Collaborators.  Beneficial  effect  of 
carotid  endarterectomy  in  symptomatic  patients 
with  high-grade  carotid  stenosis.  N Engl  J Med 
1991;325:445-453. 

7.  European  Carotid  Surgery  Trialists'  Collaborative 
Group.  MRC  European  Carotid  Surgery  Trial: 
Interim  results  for  symptomatic  patients  with 
severe  (70%  to  99%)  or  with  mild  (0%  to  29%) 
carotid  stenosis.  Eancet  1991;337:1235-1243. 

8.  Mayberg  MR,  Wilson  SE,  Yatsu  F,  et  al,  for  the 
Veterans  Affairs  Cooperative  Studies  Program  309 
Trialist  Group.  Carotid  endarterectomy  and 
prevention  of  cerebral  ischemia  in  symptomatic 
carotid  stenosis.  JAMA  1991;266:3289-3294. 

9.  Executive  Committee  for  the  Asymptomatic 
Carotid  Atherosclerosis  Study.  Endarterectomy  for 
asymptomatic  carotid  artery  stenosis.  JAMA  1995; 
273:1421-1428. 

10.  Biller  J,  Feinberg  WM,  Castaldo  JE,  et  al.  Guidelines 
for  carotid  endarterectomy:  a statement  for 
healthcare  professionals  from  a special  writing 
group  of  the  stroke  council,  American  Heart 
Association.  Stroke  1998;  29:554-562. 

11.  Moses  JW,  Roubin  GS,  Iyer  SS,  et  al.  Advanced 
Endovascular  Therapies  - 1999.  New  York  Meeting, 
June  2-4,  1999,  Manual  54-63. 

12.  Wholey  MH,  Wholey  M,  Bergeron  P,  et  al.  Current 
global  status  of  carotid  artery  stent  placement. 
Cathet  Cardiovasc  Diagn  1998;  44:1-6. 


Drs  Hanley  and  Sheridan  are  Professors  of  Medicine, 
Eouisiana  State  University  School  of  Medicine 
in  Shreveport,  Eouisiana. 

Dr  Rivera  is  Assistant  Professor  of  Radiology, 
Louisiana  State  University  School  of  Medicine 
in  Shreveport,  Louisiana. 


238  J La  State  Med  Soc  VOL  152  May  2000 


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Role  of  the  Catheter  in  the 
Treatment  of  Cardiac  Arrhythmias 

Charles  Monier,  MD;  Neeraj  Tandon,  MD;  and  Pratap  C.  Reddy,  MD 


During  the  last  decade,  there  has  been  a remarkable  shift  away  from  drug  therapy  toward 
catheter-based  treatment  of  many  tachyarrhythmias.  Catheter  ablation  using  radiofrequency 
energy  has  been  shown  to  provide  a cure  for  many  supraventricular  and  ventricular 
tachycardias  with  excellent  safety  and  has  now  become  the  first  line  of  treatment.  A review  of 
biophysics  and  biology  of  radiofrequency  energy,  the  technique  of  catheter  ablation,  and  its 
application  in  the  treatment  of  specific  tachycardias  encountered  in  clinical  practice  is  pre- 
sented. 


Until  recently,  patients  with  cardiac 
arrhythmias  were  managed  primarily 
with  antiarrhythmic  drugs.  However, 
antiarrhythmic  drug  therapy  is  limited  by  in- 
complete efficacy,  side  effects,  and,  in  some  cases, 
proarrhythmic  effects.2  Consequently,  during  the 
last  decade  we  have  moved  away  from  pharma- 
cologic therapy  to  transcatheter  ablation  ther- 
apy.23 Catheter  ablation  using  radiofrequency 
(RF)  energy  is  a safe  and  cost-  effective  treatment 
that  provides  a cure  for  many,  if  not  most,  pa- 
tients with  supraventricular  and  ventricular 
tachycardias.  The  purpose  of  this  article  is  to 
present  a brief  review  of  the  biology  of  RF  abla- 
tion, the  technique  of  catheter  ablation,  and  its 
application  in  the  treatment  of  both  supraven- 
tricular (SVT)  and  ventricular  tachycardias  (VT). 


BIOLOGY  OF 

RADIOFREQUENCY  ABLATION 

Radiofrequency  energy  is  a form  of  electromag- 
netic energy  with  a frequency  range  of  100  kHz 
to  1.5  MHz.4  However,  for  clinical  ablation  pro- 
cedures, RF  energy  only  between  the  range  of 
300  to  1000  kHz  is  used  to  avoid  muscle  stimu- 
lation and  induction  of  rapid  arrhythmias.  The 
mechanism  of  tissue  injury  in  response  to  RF 
energy  is  thermal,  resulting  in  electrosurgical 
desiccation  without  sparking  or  barotrauma.  In 
animal  studies,  acute  and  subacute  (<2  months 
duration)  lesions  produced  by  RF  energy  con- 
sisted of  areas  of  well-demarcated  coagulation 
necrosis  of  the  myocardium  without  destruction 
of  the  surrounding  normal  tissue  and  chronic 


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(>2  months  duration)  lesions  demonstrating  lo- 
calized, whitish,  thickened  scar  tissue.56 

RADIOFREQUENCY  CATHETER 
ABLATION  TECHNIQUE 

Catheter  ablation  is  performed  only  after  defin- 
ing the  mechanism  of  tachycardia  and  localiz- 
ing the  electrical  pathway  or  focus  responsible 
for  tachycardia  by  an  electrophysiologic  study. 
Under  local  anesthesia  using  percutaneous  tech- 
nique, several  multipolar  electrode  catheters  are 
introduced  into  femoral,  right  internal  jugular, 
and  subclavian  veins  and  advanced  into  the 
right  atrium,  right  ventricle,  coronary  sinus,  and 
the  His  bundle  region.  Using  programmed 
stimulation,  tachycardia  is  induced  and  its 
mechanism  defined.  Following  this,  a mapping 
and  ablating  catheter  with  a deflectable  tip  is 
introduced  into  a vein  or  an  artery,  depending 
on  whether  a tachycardia  pathway  is  localized 
to  and  accessible  from  the  right-  or  left-sided 
cardiac  chambers.  The  ablating  catheter  is  ad- 
vanced under  fluoroscopy  and  positioned  over 
the  tachycardia  pathway  or  focus  after  its  local- 
ization by  careful  mapping.  The  catheter  is  then 
connected  to  the  RF  energy  source  followed  by 
application  of  energy  for  30  to  60  seconds  with 
continuous  monitoring  of  impedance  and  tem- 
perature.7 If  the  impedance  rises  abruptly,  ap- 
plication of  energy  is  terminated,  the  catheter 
tip  checked  for  coagulum,  and  the  procedure 
repeated.  If  the  desired  temperature  (50°C  - 
65°C)  is  not  achieved  or  if  the  system's  imped- 
ance is  high,  placement  of  more  than  one  dis- 
persive electrode  on  the  thorax  will  result  in 
lower  system  impedance  and  a greater  amount 
of  power  delivery.8  During  ablation,  catheter  sta- 
bility is  continuously  assessed  by  its  fluoroscopic 
position  or  by  the  electrogram.  Catheter  stabil- 
ity, optimal  electrogram  recording,  and  achieve- 
ment of  desired  temperature  are  the  most  im- 
portant factors  in  successful  ablation.  After  cath- 
eter ablation,  programmed  stimulation  studies 
are  repeated  with  and  without  isoproterenol  to 
confirm  its  success. 


ELECTROPHYSIOLOGY  AND  CATHETER 
ABLATION  OF  SPECIFIC  TACHYCARDIAS 

A thorough  understanding  of  the  mechanisms 
of  tachycardias  is  essential  for  performing  cath- 
eter ablation  successfully.  Electrophysiologic 
studies  in  man  suggest  that  reentry  is  the  un- 
derlying mechanism  of  most  clinical 
tachycardias.9  In  a small  number  of  patients  the 
mechanism  may,  however,  be  abnormal  or  trig- 
gered automaticity.9  Electrophysiologic  mecha- 
nism and  catheter  ablation  of  specific  supraven- 
tricular and  ventricular  tachycardias  is  pre- 
sented below. 

A.  Atrioventricular  Nodal  Reentrant 
Tachycardia  (AVNRT) 

Available  evidence  from  both  animal  and  hu- 
man studies  suggests  that  AV  nodal  reentry  in- 
volves two  distinct  pathways,  known  as  slow 
and  fast  pathway,  connected  at  each  end  by  a 
common  pathway. 10  The  slowly  conducting  path- 
way has  a shorter  refractory  period  than  the  fast 
pathway  such  that  a critically  timed  atrial  pre- 
mature beat  blocks  in  the  fast  pathway  due  to 
its  longer  refractory  period  and  propagates  to 
the  ventricles  only  via  the  slow  pathway.  As  the 
impulse  propagates  over  the  slow  pathway  to 
the  ventricles  it  penetrates  the  unused  fast  path- 
way retrogradely,  propagates  back  to  the  atria, 
and  initiates  a reentrant  tachycardia.10  In  AVNRT, 
the  anterograde  and  retrograde  limbs  of  the  re- 
entrant circuit  are  formed  by  the  slow  and  fast 
pathways,  respectively.  However,  in  a small  per- 
centage of  patients  these  pathways  may  be  re- 
versed.10 

AV  nodal  reentrant  tachycardia  can  be  cured 
by  ablation  of  either  the  fast  or  slow  pathway. 
However,  because  fast  pathway  ablation  is  as- 
sociated with  a lower  rate  of  success  and  a higher 
incidence  of  complete  AV  block,  slow  pathway 
ablation  is  now  almost  exclusively  used.2311 12 
Two  methods  are  used  for  slow  pathway  abla- 
tion. The  first,  using  nonspecific  electrogram 
characteristics  such  as  an  A:V  ratio  of  <0.5,  tar- 
gets the  posteroseptal  and  mid  septal  regions  in 
a sequential  stepwise  manner  until  slow  path- 


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way  conduction  is  abolished.11  The  second  ap- 
proach is  guided  by  recording  of  slow  pathway 
potentials  with  application  of  RF  energy  to  an 
area  where  these  potentials  are  best  recorded.12 
These  two  techniques  have  similar  rates  of  suc- 
cess and  are  superior  to  fast  pathway  ablation,  a 
technique  now  used  only  when  slow  pathway 
ablation  fails.  In  the  report  by  Kay  et  al,11  suc- 
cessful slow  pathway  ablation  was  performed 
along  the  tricuspid  valve  annulus  immediately 
anterior  to  the  coronary  sinus  ostium  in  80%  of 
patients,  caudal  to  the  coronary  sinus  ostium  in 
13%,  and  within  the  coronary  sinus  ostium  in 
7%  of  patients.  In  AVNRT,  the  slow  pathway 
ablation  is  highly  successful  with  a cure  rate  of 
98%  to  100%  and  a recurrence  rate  of  0%  to  2%. 
The  reported  incidence  of  complete  AV  block 
varied  from  0%  to  1.3%.2/3/11,12  In  the  report  by 
Kay  and  Plumb,3  of  570  consecutive  patients  who 
underwent  RF  catheter  ablation  for  AVNRT,  slow 
pathway  was  ablated  in  554  patients  and  the  fast 
pathway  in  16  patients.  Post-ablation  testing 
could  not  induce  AV  nodal  reentrant  tachycar- 
dia in  569  patients.  Complete  AV  block  occurred 
in  only  4 patients  (0.7%). 

B.  Wolff-Parkinson-White  (WPW)  Syndrome 

Patients  with  WPW  syndrome  have  accessory 
connections  between  the  atria  and  ventricles  that 
provide  an  anatomic  substrate  for  atrioventricu- 
lar (AV)  reentry.  Because  the  refractory  period 
of  the  accessory  pathway  is  longer  than  the  re- 
fractory period  of  the  AV  node,  a critically  timed 
atrial  premature  beat  can  block  in  the  accessory 
pathway  and  conduct  via  the  AV  node  to  the 
ventricles.  The  impulse  may  then  engage  the 
ventricular  insertion  of  the  accessory  pathway, 
propagate  retrogradely  to  the  atria,  and  initiate 
a reentrant  tachycardia.13  In  most  patients  with 
WPW  syndrome  the  anterograde  limb  of  the  re- 
entrant circuit  is  formed  by  the  AV  node  - His 
bundle  branch  system  and  the  retrograde  limb 
by  the  accessory  pathway,  producing  a regular 
narrow  complex  (orthodromic)  tachycardia.13'14 
In  a small  percentage  of  patients,  the  pathways 
may  be  reversed  resulting  in  a regular  wide  com- 


plex (antidromic)  tachycardia.13'14  A less  com- 
mon but  a more  serious  arrhythmia  seen  in  pa- 
tients with  WPW  syndrome  is  atrial  fibrillation 
with  rapid  conduction  over  the  accessory  path- 
way which  may  deteriorate  into  ventricular  fi- 
brillation and  cause  sudden  death.13 

Atrioventricular  accessory  pathways  may  be 
located  at  any  point  along  the  tricuspid  or  mi- 
tral valve  annuli  where  the  atria  and  ventricles 
are  in  direct  continuity.  The  most  common  loca- 
tion for  accessory  pathways  is  along  the  lateral 
portion  of  the  mitral  annulus  (left  free  wall  path- 
way); they  may,  however,  be  present  in  the  right 
free  wall  or  within  the  septum.  Before  catheter 
ablation  is  attempted,  the  accessory  pathway  is 
first  localized  by  studying  the  atrial  activation 
pattern  during  tachycardia.  Extensive  catheter 
mapping  is  then  performed  and  the  pathway 
localized  by  recording  the  shortest  AV  interval 
or  high  frequency  potential  from  the  accessory 
pathway.14,15  Right  free  wall  and  most  septal  ac- 
cessory pathways  are  ablated  by  mapping  the 
atrial  or  ventricular  insertion  of  the  accessory 
pathway  along  the  tricuspid  annulus  or  the  right 
atrial  septum.  Left  AV  accessory  pathways  are 
ablated  at  their  atrial  or  ventricular  insertion 
along  the  mitral  annulus  using  the  transeptal  or 
transaortic  approach.14'15  In  the  study  by  Jackman 
et  al,15  of  166  patients  with  177  accessory  path- 
ways who  underwent  RF  catheter  ablation,  106 
accessory  pathways  were  located  on  the  left  free 
wall,  15  on  the  right  free  wall,  13  were 
anteroseptal,  and  43  were  posteroseptal  in  loca- 
tion. Radiofrequency  catheter  ablation  success- 
fully eradicated  conduction  in  174  of  177  acces- 
sory pathways  during  the  first  session.  All  three 
failures  were  in  patients  with  posterosetpal  ac- 
cessory pathway.  Two  of  these  had  repeat  cath- 
eter ablation  which  was  successful  in  one.  In  15 
(9%)  patients,  accessory  pathway  conduction  re- 
turned after  a successful  catheter  ablation  and  a 
second  attempt  was  successful  in  all  15  patients. 
With  one  ablation  session,  a permanent  cure  was 
effected  in  148  of  166  patients,  and,  with  a sec- 
ond procedure,  cure  was  obtained  in  164  of  166 
patients.  There  was  no  mortality  and  six  patients 


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had  complications  such  as  thrombosis  in  the 
right  atrium,  complete  AV  block,  hemopericar- 
dium  with  tamponade,  pericarditis,  and  femo- 
ral artery  pseudoaneurysm.  15 

C.  Atrial  Tachycardia 

Focal,  ectopic  atrial  tachycardias  are  due  to  ab- 
normal automaticity,  triggering,  or  micro  reen- 
try and  do  not  require  participation  of  the  AV 
node  or  the  ventricle  for  its  perpetuation.91619 
Atrial  tachycardias  originate  frequently  from  the 
right  atrium  and  when  they  arise  from  the  left 
atrium  their  origin  is  usually  near  the  ostia  of 
pulmonary  veins.  During  tachycardia,  the  P 
waves  are  always  visible  and  the  P wave  mor- 
phology is  different  from  that  of  sinus  rhythm. 
The  origin  of  tachycardia  can  often  be  deduced 
by  analysis  of  tachycardia  P wave  configura- 
tion.20 

Catheter  ablation,  though  difficult  and  time 
consuming,  can  provide  a cure  in  >80%  of  pa- 
tients with  atrial  tachycardia.1619  Mapping  of 
focal  atrial  tachycardias  is  done  by  activation 
mapping  and  pace  mapping.17 19  Once  the  site  of 
earliest  activation  is  identified,  atrial  pacing  is 
performed  from  that  site,  and,  if  P wave  mor- 
phology of  paced  complexes  is  identical  to  that 
of  tachycardia  P waves  in  all  12  ECG  leads,  ab- 
lation at  that  site  will  eliminate  tachycardia.17'20 
Lesh  et  al19  successfully  performed  RF  ablation 
in  11/12  (92%)  patients  with  automatic  atrial 
tachycardia  and  7/8  (88%)  with  intraatrial  reen- 
trant tachycardia.  There  were  two  recurrences 
which  were  successfully  treated  with  repeat  ab- 
lation. Morady2  reviewed  ten  studies  of  RF  cath- 
eter ablation  of  atrial  tachycardia  in  a total  of 
146  patients.  He  found  the  overall  success  rate 
to  be  92%.  The  recurrence  rate  was  8%  with  ap- 
pearance of  a different  tachycardia  in  3%  of  pa- 
tients. Complications  from  vascular  access  were 
noted  in  1.4%  of  patients.  In  the  study  by  Kay  et 
al21  of  105  consecutive  patients  who  underwent 
RF  catheter  ablation  for  atrial  tachycardia,  the 
site  of  origin  was  in  the  sinus  node  region  in  27 
patients  and  elsewhere  in  the  atria  in  78  patients. 
Catheter  ablation  was  successful  in  101  patients 
(96.2%)  with  no  complications. 


D.  Atrial  Flutter 

It  is  now  accepted  that  type  I flutter  (the  most 
common),  characterized  by  sawtooth  flutter 
waves  in  leads  II,  III  and  aVF,  is  due  to  reentry 
within  the  right  atrium.22  The  left  atrium  is  only 
passively  activated.  In  type  I flutter,  there  is 
counterclockwise  activation  of  the  right  atrium 
with  caudo-cranial  activation  along  the  right 
atrial  septum  and  cranio-caudal  activation  along 
the  right  atrial  free  wall.  The  zone  of  slow  con- 
duction in  the  atrial  flutter  reentry  circuit  is  lo- 
cated within  the  tricuspid  valve-inferior  vena 
cava  (TV-IVC)  isthmus.22 

Only  type  I atrial  flutter  can  be  successfully 
ablated.2324  Using  an  anatomically  guided  ap- 
proach, the  zone  of  slow  conduction  located 
within  the  TV-IVC  isthmus  is  targeted  for  abla- 
tion. The  ablation  catheter  is  positioned  fluoro- 
scopically  across  the  tricuspid  annulus  and  then 
withdrawn  gradually  toward  the  inferior  vena 
cava  while  RF  energy  is  applied.  Ablation  of  the 
entire  TV-IVC  isthmus  requires  several  sequen- 
tial applications  of  30  to  60  seconds  duration 
during  catheter  pull  back.  Ablation  is  considered 
successful  when  atrial  flutter  is  terminated  by 
ablation  and  a bidirectional  conduction  block  is 
created  in  the  TV-IVC  isthmus  between  coronary 
sinus  ostium  and  tricuspid  annulus.22"24  Cosio 
and  colleagues23  analyzed  the  results  in  250  pa- 
tients with  atrial  flutter  who  received  RF  abla- 
tion at  various  medical  centers.  Success  rates 
ranged  from  81%  to  100%  and  recurrence  rates 
ranged  from  9%  to  46%  with  majority  amenable 
to  repeat  ablation.  Complication  rates  of  atrial 
flutter  ablation  are  low  and  despite  ablation  in 
the  thin  walled  atrial  tissue  myocardial  perfora- 
tion is  very  rare. 

E.  Atrial  Fibrillation 

Atrial  fibrillation  is  a chaotic  rhythm  caused  by 
the  presence  in  both  atria  of  multiple  wavelets 
that  are  fleeting  both  in  time  and  location.9  More 
recently,  focal  atrial  fibrillation  originating  near 
the  ostia  of  great  veins  has  been  described  in 
patients  without  structural  heart  disease.25  Three 
different  catheter  ablation  approaches  are  used 


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in  atrial  fibrillation.  These  are  AV  nodal  abla- 
tion and  AV  nodal  modification  to  control  the 
ventricular  rate  and  primary  ablation  of  atrial 
fibrillation  to  maintain  sinus  rhythm.26'28 

In  AV  nodal  ablation,  the  ablating  catheter 
is  placed  across  the  tricuspid  valve  in  the  re- 
gion of  the  compact  AV  node.  Once  a stable  elec- 
trogram is  achieved,  RF  energy  is  applied  to 
produce  complete  AV  block.  AV  nodal  ablation 
successfully  produces  complete  AV  block  in  90% 
of  the  patients.26  28  In  10%  of  patients,  AV  block 
is  difficult  to  create  because  of  anatomic  distor- 
tion, catheter  instability,  or  inadequate  tissue 
beating.  All  patients  who  undergo  AV  nodal 
ablation  require  permanent  pacing.  AV  node 
modification  by  ablation  in  the  region  of  AV 
nodal  slow  pathway  has  been  shown  to  slow 
ventricular  response  to  AF.27  Though  an  alter- 
native to  total  ablation,  AV  node  modification 
is  seldom  used  because  of  the  need  for  contin- 
ued drug  therapy  for  rate  control  in  many  pa- 
tients and  the  relatively  high  incidence  of  inad- 
vertent complete  AV  block.  Patients  undergo- 
ing AV  node  modification  or  ablation  require 
long-term  anticoagulation. 

Ablation  of  atrial  fibrillation  to  effect  a cure 
is  presently  under  investigation.29'31  In  this  pro- 
cedure, long  linear  lesions  are  made  in  both  the 
atria  to  block  pathways  of  intraatrial  reentry  and 
prevent  propagation  of  atrial  fibrillation.  Swartz 
et  al29  achieved  a success  rate  of  80%  in  34  pa- 
tients with  chronic  atrial  fibrillation  by  creating 
linear  lesions  in  both  atria.  The  procedures  were 
prolonged,  required  general  anesthesia,  and  two 
patients  developed  an  embolic  cerebrovascular 
accident.29  In  patients  with  focal  atrial  fibrilla- 
tion originating  near  the  pulmonary  veins,  ab- 
lation of  these  foci  has  resulted  in  cure  in  all  pa- 
tients.25 However,  this  is  a time-consuming  pro- 
cedure with  significant  complications  such  as 
pulmonary  vein  thrombosis,  pulmonary  hyper- 
tension, and  cerebrovascular  accident.25 

F.  Idiopathic  Ventricular  Tachycrdia 

Idiopathic  VT  is  seen  in  patients  with  no  evi- 
dence of  structural  heart  disease  and  originates 
from  the  right  ventricular  outflow  tract  or  the 


inferior  left  ventricular  septum.32  33  Electrophysi- 
ologic  studies  suggest  its  mechanisms  to  be  trig- 
gered automaticity  or  calcium  channel  depen- 
dent reentry.9 

Idiopathic  VT  can  be  successfully  ablated  in 
greater  than  90%  of  patients  using  activation 
mapping  and  pace  mapping  techniques.  In  idio- 
pathic VT  originating  from  the  right  ventricle, 
mapping  is  performed  in  the  right  ventricular 
infundibulum  and  along  the  interventricular  sep- 
tum until  a site  with  local  activation  preceding 
QRS  by  20-80  ms  is  identified.  If  pacing  from  that 
site  produces  QRS  complexes  that  are  identical 
to  those  of  spontaneous  VT  in  at  least  11  of  12 
ECG  leads,  application  of  RF  energy  at  that  site 
will  abolish  VT.32 

Mapping  of  idiopathic  VT  originating  from 
the  left  ventricle  is  done  by  recording  a Purkinje 
or  "P"  potential,  preceding  the  onset  of  QRS 
during  tachycardia.33  In  the  absence  of  a Purkinje 
potential,  activation  mapping  and  pace  mapping 
as  described  above  are  used.  Application  of  RF 
energy  at  a ventricular  site  where  the  Purkinje 
potential  precedes  QRS  complex  by  greater  than 
20  ms  successfully  eliminates  VT.  Application  of 
RF  energy  at  a successful  ablation  site  typically 
initiates  a transient  tachycardia  or  accelerates  the 
existing  tachycardia  followed  by  slowing  and  ter- 
mination of  tachycardia  within  15  seconds.  If  this 
pattern  is  not  observed  or  if  tachycardia  contin- 
ues, energy  delivery  is  terminated  and  mapping 
repeated  to  find  a more  precise  site  of  origin  of 
the  tachycardia.3233 

G.  Ventricular  Tachycardia  in  Patients  with 
Structural  Heart  Disease 

The  mechanism  of  VT  in  patients  with  structural 
heart  disease  is  micro  reentry  within  the  ventricu- 
lar myocardium.9  However,  in  a small  number 
of  patients  the  reentrant  circuit  may  be  confined 
to  bundle  branches  with  passive  activation  of  the 
ventricles.34  Catheter  ablation  of  micro  reentrant 
VT  results  in  cure  in  only  60%  to  80%  of  patients 
because  of  difficulty  in  localizing  the  zone  of  slow 
conduction.2'3'35  36  Also,  the  site  of  origin  of  VT  is 
frequently  subepicardial  or  intramural  and  the 
shallow  depth  of  ablation  that  can  be  achieved 


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Cardiovascular  Disease 
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with  RF  energy  sometimes  precludes  ablation 
success  even  when  the  zone  of  slow  conduc- 
tion can  be  identified.2'33536  Catheter  ablation 
of  VT  associated  with  heart  disease  is  further 
complicated  by  the  fact  that  most  patients  can- 
not tolerate  the  tachycardia  for  the  prolonged 
periods  of  time  required  for  successful  mapping 
of  the  tachycardia  focus.  Consequently,  only  a 
selected  group  of  patients  with  microreentrant 
VT  can  undergo  catheter  ablation.  In  contrast, 
a cure  can  be  effected  in  all  patients  with  bundle 
branch  reentry  tachycardias  by  ablating  the 
right  bundle  branch.34  No  recurrence  of  tachy- 
cardia has  been  reported  in  patients  with 
bundle  branch  reentry  following  successful 
ablation.34 

INDICATIONS  FOR  RADIOFREQUENCY 
CATHETER  ABLATION 

Catheter  ablation  is  considered  appropriate 
first  line  of  therapy  for  patients  with  parox- 
ysmal supraventricular  tachycardia,  atrial 
flutter,  or  idiopathic  ventricular  tachycardia 
who  have  sufficient  symptoms  to  justify  treat- 
ment.23 In  patients  with  atrial  fibrillation,  AV 
nodal  ablation  is  indicated  when  antiarrhyth- 
mic  therapy  is  ineffective  or  contraindicated.28 
In  patients  with  VT  associated  with  heart 
disease,  RF  catheter  ablation  is  used  only  in 
selected  patients  with  slower  rates  of  tachy- 
cardia or  as  an  adjunct  therapy  in  patients 
who  already  have  cardioverter  defibrillators 
implanted. 

BENEFITS  OF  CATHETER  ABLATION 

The  benefits  of  catheter  ablation  include  relief 
of  symptoms,  improvement  in  quality  of  life, 
elimination  of  the  need  for  life-long  antiarrhyth- 
mic  therapy,  and  long-term  cost  savings.37"39  In 
patients  with  atrial  fibrillation  with  uncon- 
trolled ventricular  rate  or  with  chronic  persis- 
tent atrial  tachycardia,  catheter  ablation  will 
prevent  the  development  of  tachycardia  depen- 
dent cardiomyopathy  and  congestive  heart  fail- 
ure. Comparative  studies  have  shown  that  the 
cost  of  an  ablative  procedure  is  significantly  less 


than  the  cumulative  cost  of  drug  therapy  and 
emergency  room  visits  for  treatment  of  parox- 
ysmal SVT.38'39 

RISKS  OF  CATHETER  ABLATION 

The  most  common  risks  of  catheter  ablation  in- 
clude those  associated  with  vascular  access,  such 
as  hematoma,  deep  vein  thrombosis,  pneu- 
mothorax, pseudo-aneurysm  formation,  and  ar- 
teriovenous fistula.231215  Rare  complications  in- 
clude cardiac  perforation  with  hemopericardium 
and  tamponade,  pericarditis,  and  complete  AV 
block  with  need  for  permanent  pacing.2'31215  Very 
rare  complications  include  thrombosis  at  the 
ablation  site  with  risk  of  embolization,  skin  in- 
jury from  radiation  due  to  prolonged  fluoros- 
copy, perforation  of  aortic  valve  leaflet  resulting 
in  aortic  regurgitation,  and  embolic  cerebrovas- 
cular accident.23 

CONCLUSIONS 

Our  ability  to  eradicate  tachycardia  with  a cath- 
eter in  the  heart  has  completely  changed  our 
approach  to  treatment  of  cardiac  arrhythmias. 
RF  catheter  ablation  has  now  become  the  first 
line  of  treatment  in  most  patients  with  supraven- 
tricular and  ventricular  tachycardias.  Unlike 
antiarrhythmic  drugs,  catheter  ablation  provides 
a cure  with  an  acceptable  risk  profile.  In  the  fu- 
ture, new  catheter  designs,  better  mapping  tech- 
niques, and  availability  of  alternative  power 
sources  with  greater  capability  for  deep  tissue 
heating  such  as  microwave  and  ultrasound  en- 
ergy would  make  catheter  ablation  more  effec- 
tive with  fewer  complications. 

REFERENCES 

1.  Coplen  SE,  Antman  EM,  Berlin  JA,  et  al.  Efficacy 
and  safety  of  quinidine  therapy  for  maintenance  of 
sinus  rhythm  after  cardioversion:  a meta  analysis 
of  randomized  controlled  trials.  Circulation  1990; 
82:1106-1116. 

2.  Morady  F.  Radiofrequency  ablation  as  treatment  for 
cardiac  arrhythmias.  N Engl  J Med  1999;340:534-44. 

3.  Kay  GN,  Plumb  VJ.  The  present  role  of 


244  J La  State  Med  Soc  VOL  152  May  2000 


Cardiovascular  Disease 
in  Louisiana 


radiofrequency  catheter  ablation  in  the  man- 
agement of  cardiac  arrhythmias.  Am  J Med 
1996;100:334-356. 

4.  Nath  S,  DiMarco  JP,  Haines  DE.  Basic  aspects  of 
radiofrequency  catheter  ablation.  / Cardiovasc 
Electrophysiol  1995;5:863-876. 

5.  Nath  S.  Radiofrequency  catheter  ablation.  How 
does  it  work?  Cardiol  Rev  1995;3:117-124. 

6.  Huang  SKS,  Graham  AR,  Bharatis,  et  al.  Short-  and 
long-term  effects  of  transcatheter  ablation  of  the 
coronary  sinus  by  radiofrequency  energy.  Circula- 
tion 1988;78:416-427. 

7.  Calkins  H,  Prystowsky  E,  Carlson  M.  Temperature 
monitoring  during  radiofrequency  catheter  abla- 
tion procedures  using  closed  loop  control.  Circu- 
lation 1994;90:1279-1286. 

8.  Nath  S,  DiMarco  JP,  Gallop  RG,  et  al.  Effects  of 
dispersive  electrode  position  and  surface  area  on 
electrical  parameters  and  temperatures  during 
radiofrequency  catheter  ablation.  Am  J Cardiol 
1996;77:765-767. 

9.  Zipes  DP,  Jalife  J.  Cardiac  Electrophysiology . From 
Cell  to  Bedside.  Orlando:  WB  Saunders;  1990. 

10.  Denes  P,  Wu  D,  Dhingra  R,  et  al.  Demonstration 
of  dual  AV  nodal  pathways  in  patients  with  par- 
oxysmal supraventricular  tachycardia.  Circulation 
1973;48:549-556. 

11.  Kay  GN,  Epstein  AE,  Daily  SM,  et  al.  Selective 
radiofrequency  ablation  of  the  slow  pathway  for 
the  treatment  of  atrioventricular  nodal  reentrant 
tachycardia:  evidence  for  involvement  of  per- 
inodal  myocardium  within  the  reentrant  circuit. 
Circulation  1992;85:1675-1688. 

12.  Jackman  WM,  Beckman  KJ,  McClelland  JH,  et  al. 
Treatment  of  supraventricular  tachycardia  due  to 
atrioventricular  nodal  reentry  by  radiofrequency 
catheter  ablation  of  slow-pathway  conduction.  N 
Engl  J Med  1992;327:313-318. 

13.  Gallagher  JJ,  Gilbert  M,  Svenson  RH,  et  al.  Wolff- 
Parkinson-White  Syndrome.  The  problem  evalu- 
ation and  surgical  correction.  Circulation 
1975;51:167-179. 

14.  Calkins  H,  Langberg  J,  Sousa  J,  et  al. 
Radiofrequency  catheter  ablation  of  accessory 
atrioventricular  connections  in  250  patients:  abbre- 
viated therapeutic  approach  to  Wolff-Parkinson- 
White  syndrome.  Circulation  1992;85:1337-1346. 

15.  Jackman  WM,  Wang  X,  Friday  KJ,  et  al.  Catheter 
ablation  of  accessory  atrioventricular  pathways 
(Wolff-Parkinson-White  syndrome)  by  radiofre- 
quency current.  N Engl  J Med  1991;324:1605-1611. 

16.  Chen  SA,  Chiang  CE,  Yang  CJ,  et  al.  Sustained 
atrial  tachycardia  in  adult  patients:  electrophysi- 
ological  characteristics,  pharmacological  response. 


possible  mechanisms  and  effects  of  radiofrequency 
ablation.  Circulation  1994;90:1262-1278. 

17.  Tracy  CM,  Swartz  JE,  Fletcher  RD,  et  al. 
Radiofrequency  catheter  ablation  of  ectopic  atrial 
tachycardia  using  paced  activation  sequence  map- 
ping. / Am  Coll  Cardiol  1993;21:910-917. 

1 8 . Chen  SA,  Chiang  CE,  Yang  CJ,  et  al.  Radiofrequency 
catheter  ablation  of  sustained  intra-atrial  reentrant 
tachycardia  in  adult  patients:  identification  of  elec- 
trophysiological  characteristics  and  endocardial 
mapping  techniques.  Circulation  1993;  88:578-587. 

19.  Lesh  MD,  Van  Hare  GF,  Epstein  LM,  et  al. 
Radiofrequency  catheter  ablation  of  atrial 
arrhythmias:  results  and  mechanisms.  Circulation 
1994;87:1074-1089. 

20.  Lesh  MD,  Van  Hare  GF,  Epstein  LM,  et  al. 
Radiofrequency  catheter  ablation  for  atrial 
arrhythmias:  results  and  mechanisms.  Circulation 
1994;87:1074-1089. 

21.  Kay  GN,  Chong  F,  Epstein  AE,  et  al. 
Radiofrequency  ablation  for  treatment  of  primary 
atrial  tachycardias.  J Am  Coll  Cardiol  1993;21:901- 
909. 

22.  Shah  DC,  Haissaguerre  M,  Jais  P,  et  al.  Atrial  flut- 
ter: contemporary  electrophysiology  and  catheter 
ablation.  Pacing  Clin  Electrophysiol  1999;22:344-359. 

23.  Cosio  FG,  Arribas  F,  Lopez-Gill  M,  et  al.  Atrial  flut- 
ter mapping  and  ablation  II:  radiofrequency  abla- 
tion of  atrial  flutter  circuits.  Pacing  Clin 
Electrophysiol  1996;19:965-9 75. 

24.  Fischer  B,  Jais  P,  Shah  D,  et  al.  Radiofrequency  cath- 
eter ablation  of  common  atrial  flutter  in  200  pa- 
tients. J Cardiovasc  Electrophysiol  1996;7:1225-1233. 

25.  Jai  P,  Haissaguerre  M,  Shah  DC,  et  al.  A focal  source 
of  atrial  fibrillation  treated  by  radiofrequency  ab- 
lation. Circulation  1997;95:572-576. 

26.  Brignole  M,  Menozzi  C.  Control  of  rapid  heart  rate 
in  patients  with  atrial  fibrillation:  drugs  or  abla- 
tion? Pacing  Clin  Electrophysiol  1996;19:348-356. 

27.  Morady  F,  Hasse  C,  Strickberger  SA,  et  al.  Long- 
term follow-up  after  radiofrequency  modification 
of  the  atrioventricular  node  in  patients  with  atrial 
fibrillation.  / Am  Coll  Cardiol  1997;29:113-121. 

28.  Viskin  S,  Barron  HV,  Heller  K,  et  al.  The  treatment 
of  atrial  fibrillation:  pharmacologic  and  non-phar- 
macologic  strategies.  Current  Proh  Cardiol 
1997;22:37-108. 

29.  Swartz  JF,  Pellersels  G,  Silvers  J,  et  al.  A catheter 
based  curative  approach  to  atrial  fibrillation  in 
humans  (abstract).  Circulation  1994;96:1-335. 

30.  Haissaguerre  M,  Jais  P,  Shah  DC,  et  al.  Right  and 
left  atrial  radiofrequency  catheter  therapy  of  par- 
oxysmal atrial  fibrillation.  / Cardiovasc  Electrophysiol 
1996;  7:1132-1144. 


J La  State  Med  Soc  VOL  152  May  2000  245 


Cardiovascular  Disease 
in  Louisiana 


31.  Maloney  JD,  Milner  L,  Barold  S,  et  al.  Two-staged 
biatrial  linear  and  focal  ablation  to  restore  sinus 
rhythm  in  patients  with  refractory  chronic  atrial 
fibrillation:  procedure  experience  and  follow-up 
beyond  1 year.  Pacing  and  Clin  Electrophysiol 
1998;21:2527-2532. 

32.  Klein  LS,  Shih  HT,  Hackett  FK,  et  al. 
Radiofrequency  catheter  ablation  of  ventricular 
tachycardia  in  patients  without  structural  heart 
disease.  Circulation  1992;85:1666-1674. 

33.  Nakagawa  H,  Beckman  K,  McClelland  J,  et  al. 
Radiofrequency  catheter  ablation  of  idiopathic  left 
ventricular  tachycardia  guided  by  a Purkinje  po- 
tential. Circulation  1993;88:2607-2617. 

34.  Blanck  Z,  Dhala  A,  Deshpande  S,  et  al.  Bundle 
branch  reentrant  tachycardia.  Cumulative  experi- 
ence in  48  patients.  J Cardiovasc  Electrophysiol 
1993;4:253-262. 

35.  Rothman  SA,  Hsia  HH,  Cossu  S,  et  al. 
Radiofrequency  catheter  ablation  of  post-infarction 
ventricular  tachycardia:  long-term  success  and  the 
significance  of  non-inducible  clinical  arrhythmias. 
Circulation  1997;96:3499-3508. 

36.  Stevenson  WG,  Hafzia  K,  Sager  P,  et  al.  Identifica- 
tion of  reentry  circuit  sites  during  catheter  map- 
ping and  radiofrequency  ablation  of  ventricular 
tachycardia  late  after  myocardial  infarction.  Circu- 
lation 1993;88:1647-1670. 

37.  Bubien  RS,  Knotts-Dolson  SM,  Plumb  VJ,  et  al.  Ef- 
fect of  radiofrequency  catheter  ablation  on  health- 
related  quality  of  life  and  activities  of  daily  living 
in  patients  with  recurrent  arrhythmias.  Circulation 
1996;94:1585-1591. 

38.  Man  KC,  Kalbfleisch  SJ,  Hummel  JD,  et  al.  Safety 
and  cost  of  outpatient  radiofrequency  ablation  of 
the  slow  pathway  in  patients  with  atrioventricular 
nodal  reentrant  tachycardia.  Am  J Cardiol 
1993;72:1323-1234. 

39.  Kalbfleisch  SJ,  Calkins  H,  Langberg  JJ,  et  al.  Com- 
parison of  the  cost  of  radiofrequency  catheter  modi- 
fication of  the  atrioventricular  node  and  medical 
therapy  for  drug-refractory  atrioventricular  nodal 
reentrant  tachycardia.  / Am  Coll  Cardiol 
1992;19:1583-158 7. 


Drs  Monier  and  Tandon  are  Fellows  in  Cardiology  and 
Dr  Reddy  is  a Professor  of  Medicine,  from  the 
Department  of  Medicine,  Cardiology  Section, 
Louisiana  State  University  School  of  Medicine, 

Shreveport,  Louisiana. 


246  J La  State  Med  Soc  VOL  152  May  2000 


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Renovascular  Hypertension: 
Screening  and  Therapeutic  Options 


Edwin  Rivera,  MD  and  Horacio  D’Agostino,  MD 


Renovascular  hypertension  is  part  of  the  spectrum  of  hypertensive  disease.  Although  uncommon 
(1%  to  5%  of  the  cases)  in  comparison  to  essential  hypertension,  it  is  a potentially  curable  form  of 
the  disease.  We  review  the  different  tools  available  for  the  evaluation  and  treatment  of  this  condition. 


O.ne  of  the  biggest  challenges  physicians 
face  involves  the  management  of  hyper 
tensive  patients.  The  physician  must  de- 
cide which  one  of  these  patients  might  have  sec- 
ondary hypertension,  which  one  needs  to  be 
screened,  what  tools  are  available  for  screening, 
and  what  treatment  options  are  available.  While 
keeping  in  mind  the  high  complexity  of  this 
problem  we  will  try  to  review  these  issues  in  a 
simple  fashion. 

The  World  Health  Organization  has  defined 
hypertension  as  a peak  systolic  pressure  greater 
than  or  equal  to  140  mm  Hg  or  a diastolic  pres- 
sure greater  than  or  equal  to  90  mm  Hg.  It  is 
estimated  that  60  million  Americans  are  affected 
by  this  condition. 


DEFINITION 

Essential  hypertension  is  the  term  applied  to  the 
condition  when  the  cause  of  the  elevation  in 
blood  pressure  is  unknown.  This  represents  the 
great  majority  of  the  cases.1 

It  is  estimated  that  only  1%  to  5%  of  hyper- 
tensive patients  have  secondary  hypertension, 
and  of  this  group  those  with  reno-vascular  hy- 
pertension (RVH)  represent  the  vast  majority. 
Conditions  that  are  associated  with  RVH  include 
atherosclerosis,  fibro-muscular  dysplasia,  sys- 
temic arteritis,  thrombosis,  and  dissection. 

Atherosclerosis  of  the  aorta  can  involve  the 
origin  of  the  renal  arteries  or  the  main  renal  ar- 
teries causing  renal  artery  stenosis  (RAS).  It  is 


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Cardiovascular  Disease 
in  Louisiana 


most  commonly  seen  in  older  patients,  especially 
in  males,  and  is  present  in  approximately  two 
thirds  of  the  cases  of  renovascular  hypertension. 
On  physical  examination  an  epigastric  bruit 
might  be  present.  Angiography  frequently  dem- 
onstrates associated  aortic  disease,  and  in  30% 
to  50%  of  the  cases  the  renal  lesions  tend  to  be 
bilateral.2 

Fibro-muscular  dysplasia  (FMD)  represents 
a group  of  non-atherosclerotic  vascular  lesions 
affecting  the  arterial  wall.  There  are  four  differ- 
ent types  described:  medial  fibroplasia  repre- 
senting 60%  to  70%  of  the  cases,  perimedial  fi- 
broplasia 15%  to  25%,  intimal  fibroplasia  <5%, 
and  medial  hyperplasia  <5%.  The  first  two  types 
tend  to  produce  a characteristic  beaded  appear- 
ance of  the  renal  arteries,  affect  adults  (particu- 
larly females),  and  are  often  bilateral.  The  last 
two  categories  tend  to  affect  children  and  teen- 
agers and  present  as  a smooth  narrowing  at  an- 
giography.3 

SCREENING  METHODS 

A great  number  of  articles  have  been  published 
evaluating  the  effectiveness  of  imaging  stud- 
ies in  the  evaluation  of  secondary  hyperten- 
sion. 

Several  screening  methods  for  the  evaluation 
of  patients  with  renovascular  hypertension  have 
been  developed.  Most  of  these  are  performed 
using  ultrasound,  nuclear  medicine,  or  angiog- 
raphy. Other  newer  techniques  include  Com- 
puted Tomographic  Angiography  (CTA)  and 
Magnetic  Resonance  Angiography  (MRA). 
These  studies  must  demonstrate  a high  sensi- 
tivity and  specificity  in  order  to  be  useful  to  the 
clinician. 

Several  clinical  findings  have  been  identified 
in  the  literature  that  suggest  a higher  incidence 
of  RAS  in  hypertensive  patients.  These  includes 
(1)  difficult  to  control  hypertension  in  compli- 
ant patients  using  two  or  more  medications  for 
blood  pressure  control,  (2)  worsening  of  renal 
function  in  patients  taking  ACE  inhibitors,  and 
(3)  flash  pulmonary  edema.  These  groups  of 


patients  should  be  thoroughly  evaluated  for  the 
presence  of  RAS. 

When  patients  are  evaluated  for  RAS,  it  is 
useful  to  divide  the  screening  studies  into  two 
different  categories,  those  that  evaluate  renal 
function  and  those  that  demonstrate  anatomic 
lesions. 

FUNCTIONAL  STUDIES 

Captopril  Renography 

Angiotensin  inhibitors  have  been  used  as  a func- 
tional screening  test  for  reno- vascular  hyperten- 
sion. Several  different  radiopharmaceuticals  or 
tracers  may  be  used  for  the  evaluation  of  renal 
function.  We  will  concentrate  in  the  use  of  tech- 
netium diethylenetriaminepentaacetic  acid  (Tc- 
DTPA).  Tc-DTPA  is  one  of  the  agents  used  for 
the  evaluation  of  glomerular  filtration  rate. 

The  development  of  renovascular  hyperten- 
sion depends  on  the  secretion  of  renin  from  the 
juxtaglomerular  system  in  the  kidney.  Renal  ar- 
tery stenosis  increases  renin  production.  The  use 
of  ACE  inhibitors  blocks  the  conversion  of  an- 
giotensin I to  angiotensin  II  so  the  vasoconstric- 
tor effect  of  the  angiotensin  II  is  lost.  This  affects 
the  glomerular  filtration  rate  and  decreases  the 
uptake  of  Tc-DTPA  in  the  affected  kidney. 

There  are  several  protocols  used  to  perform 
renography  after  ACE  inhibitors  (also  known  as 
Captopril  Renography).  At  our  institution  a 1- 
day  protocol  is  used.  In  this  protocol  25-50  mg 
of  captopril  are  administered  after  a baseline 
blood  pressure  is  obtained.  The  blood  pressure 
is  subsequently  checked  every  15  minutes  for  1 
hour.  At  this  time  the  Tc-DTPA  is  injected  and 
imaging  of  both  kidneys  performed.  In  the  af- 
fected kidney,  decrease  in  the  tracer  uptake,  pro- 
longation of  the  time  to  obtained  maximum 
tracer  activity  (T  Max),  and  prolongation  in  the 
time  to  clear  the  tracer  can  be  identified.  If  the  1- 
day  study  is  positive  then  a baseline  study  is 
performed  to  increase  the  sensitivity  of  the  study. 
In  this  second  study,  the  Tc-DTPA  is  adminis- 
tered but  no  ACE  inhibitors  are  used.  This 
should  demonstrate  symmetric  uptake  of  the 


248  J La  State  Med  Soc  VOL  152  May  2000 


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tracer  in  both  kidneys  as  well  as  similar  time  to 
achieve  maximal  tracer  activity  and  a similar 
decrease  in  tracer  activity  over  time  as  the  effect 
of  the  angiotensin  II  is  not  blocked. 

Patient  preparation  prior  for  this  study  is 
critical  in  order  to  obtained  a reliable  result.  Pa- 
tients should  be  well  hydrated  prior  to  the  study, 
and  it  is  recommended  to  hydrate  the  patient 
orally  with  5-10  mL/kg  30-60  min  prior  to  the 
study.  ACE  inhibitors  should  be  discontinued  if 
possible  several  days  prior  to  the  procedure. 
ACE  inhibitors  such  as  captopril,  lisinopril,  and 
enalapril  can  decrease  the  sensitivity  of  the 
study,  and  for  this  reason  it  is  recommended  to 
discontinue  these  medications  3-7  days  prior  to 
the  study,  if  possible.  Diuretic  agents  like  furo- 
semide  can  cause  dehydration,  increasing  the 
risk  of  hypotension  during  the  study,  and  for  this 
reason  it  is  recommended  to  stop  their  use  sev- 
eral days  prior  to  the  study. 

The  sensitivity  and  specificity  reported  for 
the  renography  after  ACE  inhibitors  is  80%  to 
90%,  with  better  results  seen  in  those  studies  that 
use  normalization  or  reduction  in  blood  pres- 
sure as  the  end  point.4  It  is  important  for  the  re- 
ferring physician  to  discuss  the  procedure  with 
the  nuclear  medicine  physician  at  his  institution 
as  different  protocols  are  available  that  can  be 
used  for  the  most  appropriate  evaluation  of  ren- 
ovascular hypertension.  This  also  should  result 
in  the  referring  physician  having  a better  under- 
standing of  the  reported  results.  Remember  that 
the  sensitivity  and  specificity  of  the  study  will 
depend  on  those  factors  previously  described. 

ANATOMIC  STUDIES 

Doppler  Ultrasound 

Color  Doppler  ultrasound  is  one  of  the  modali- 
ties used  to  evaluate  renal  arteries  for  the  pres- 
ence of  RAS.  One  of  the  major  advantages  of 
color  Doppler  ultrasound  is  the  noninvasive 
nature  of  the  study,  the  lack  of  radiation,  and 
the  wide  availability  of  the  equipment.  Some  of 
the  disadvantages  of  the  study  are  the  lack  of 
standardization  and  the  wide  differences  in  ac- 


curacy in  detecting  significant  RAS.5  The 
sonographer  performing  the  study  should  be 
highly  experienced  in  the  evaluation  of  renal 
arteries  in  order  to  obtain  a reliable  study.  The 
patient's  ability  to  cooperate  with  the  study, 
body  habitus,  and  the  lack  of  bowel  gas  are  other 
factors  that  may  determine  if  an  adequate  study 
can  be  obtained. 

Recent  studies  have  demonstrated  that  the 
best  Doppler  identifiable  parameter  that  corre- 
lates with  RAS  is  the  peak  systolic  velocity  in 
the  renal  artery  (a  sensitivity  of  95%  and  a speci- 
ficity of  90%  were  demonstrated  if  the  velocity 
in  the  main  renal  artery  was  greater  than  180  cm/ 
sec).6  The  second  best  parameter  was  a renal- 
aortic  ratio  greater  than  3.3  for  the  detection  of 
RAS  > 60%. 

Since  the  visualization  of  the  entire  main  re- 
nal artery  is  not  always  possible,  others  findings, 
such  as  the  presence  of  a tardus-parvus  wave- 
form in  the  intra-renal  branches,  have  been  used 
as  a way  to  evaluate  for  RAS.  This,  however,  has 
been  recently  criticized  because  it  is  dependent 
on  blood  pressure  and  the  compliance  of  intra- 
renal  vessels  thus  limiting  the  usefulness  of  this 
technique. 

Recent  published  reports  regarding  the  use 
of  new  ultrasound  contrast  agents  in  the  evalu- 
ation of  RAS  have  demonstrated  a significant 
improvement  in  the  visualization  of  the  renal 
arteries.7 

Computed  Tomographic  Angiography  (CTA)  and 
Magnetic  Resonance  Angiography  (MRA) 

CTA  and  MRA  are  two  of  the  newest  imaging 
technologies  used  in  the  evaluation  of  patients 
with  suspected  RAS.  CTA  uses  thinly  collimated 
tomographic  slices  (<2mm)  of  the  abdomen  in 
order  to  obtain  images  of  the  renal  arteries.  The 
scanned  area  extends  from  above  the  origin  of 
the  superior  mesenteric  artery  to  below  the  aor- 
tic bifurcation  in  order  to  include  any  possible 
accessory  renal  arteries  that  might  be  present. 

CTA  has  been  demonstrated  to  have  a sensi- 
tivity and  specificity  in  the  90%  range,  using  state 
of  the  art  equipment.  Some  of  the  advantages  of 


J La  State  Med  Soc  VOL  152  May  2000  249 


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CTA  include  the  visualization  of  calcified  and 
non-calcified  plaques  in  the  renal  arteries  and 
reduced  cost  compared  to  MRA.  Some  of  the 
disadvantages  of  CTA  include  the  need  for  ra- 
diation and  iodinated  contrast.8 

Magnetic  resonance  angiography  is  being 
used  more  often  for  the  evaluation  of  RAS  (Fig- 
ure 1).  Several  of  the  advantages  of  MRA  over 
CTA  include  the  lack  of  radiation  and  the  use  of 
paramagnetic  agents  such  as  gadolinium  com- 
plexes that  do  not  have  the  nephrotoxicity  asso- 
ciated to  iodinated  contrast.  Also,  the  effects  of 
the  stenosis  in  the  affected  kidney  can  be  evalu- 
ated. For  example,  the  renal  size,  cortical  thick- 
ness, renal  parenchyma  enhancement,  and  ex- 
cretory function  of  the  kidney  can  be  evaluated. 
The  visualization  of  small  accessory  renal  arter- 
ies with  MRA,  however,  can  be  difficult,  espe- 
cially in  those  cases  where  spatial  resolution  is 
sacrificed  in  order  to  obtain  a field  of  view  large 
enough  to  cover  the  entire  blood  supply  to  the 
kidneys.  Other  factors  that  can  affect  the  quality 
of  the  study  include  acquisition  parameters,  the 
patient's  ability  to  hold  his  breath  during  the  time 
required  to  acquire  the  images,  and  the  contrast 
bolus  timing.  These  factors  should  be  weighted 


Figure  1 . Patient  referred  for  evaluation  of  sudden  on- 
set hypertension.  Contrast  MRA  in  the  coronal  plane 
demonstrating  a severe  stenosis  of  the  main  right  renal 
artery.  Note  the  drop  in  signal  intensity  as  compared  to 
the  left  side. 


and  discussed  with  the  radiologist  in  order  to 
maximize  the  utility  of  the  study.  The  sensitiv- 
ity and  specificity  of  MRA  has  been  reported  to 
be  over  90%  in  several  series.9 

CONVENTIONAL  ANGIOGRAPHY 

Conventional  angiography  has  been  considered 
the  gold  standard  for  the  evaluation  of  renal  ar- 
tery stenosis  as  it  provides  a direct  way  to  visu- 
alize the  renal  arteries  (Figure  2).  The  visualiza- 
tion of  the  intra-renal  vessels  as  well  as  the 
evaluation  of  the  aorta  and  the  presence  of  small 
accessory  renal  branches  are  some  of  the  other 
advantages  of  this  method. 

Some  of  the  disadvantages  of  conventional 
angiography  include  the  fact  that  it  is  an  inva- 
sive procedure  and  the  need  for  contrast  me- 
dia. Complications  include  hematomas,  dissec- 
tion or  occlusion  of  blood  vessels,  nephrotoxic- 
ity, and  allergic  reactions.  These  complications 
can  be  reduced  if  the  procedure  is  performed 
by  an  interventionist  trained  in  the  use  of  cath- 
eters and  wires  and  by  strict  adherence  to  good 
technique.  Adequate  patient  preparation  is  of 
utmost  importance.  Several  reports  of  alterna- 
tive contrast  media  such  as  carbon  dioxide  and 
gadolinium,  used  as  a single  agent  or  in  combi- 
nation, suggest  that  they  can  be  a safe  alterna- 
tive in  patients  with  renal  insufficiency.10 


Figure  2.  Same  patient  as  Figure  1.  Conventional  an- 
giogram demonstrating  a severe  narrowing  in  the  right 
main  renal  artery  as  seen  on  MRA. 


250  J La  State  Med  Soc  VOL  152  May  2000 


Cardiovascular  Disease 
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THERAPEUTIC  APPROACHES  TO 
RENAL  ARTERY  STENOSIS 

The  treatment  of  RAS  has  been  centered  on  two 
major  modalities:  endovascular  therapy  or  con- 
ventional surgery.  Each  one  of  these  techniques 
has  its  own  advantages  and  disadvantages. 

The  surgical  alternatives  for  the  treatment  of 
RAS  include  endarterectomy,  reimplantation  of 
the  renal  artery,  bypass  using  endogenous  or 
synthetic  materials,  spleno-renal  shunt,  and 
auto-transplantation.11  Mortality  rates  of  2% 
have  been  reported  in  several  series.  Cure  or 
improvement  of  blood  pressure  has  been  re- 
ported in  the  90%  range,  with  cure  or  improve- 
ment in  renal  function  reported  in  the  75%  to 
90%  range. 

Endovascular  treatment  of  RAS  is  a well-es- 
tablished procedure  in  the  interventional  litera- 
ture. It  is  considered  the  first  line  of  therapy  in 
those  patients  with  hypertension  associated  with 
FMD.12  In  those  patients  with  hypertension  sec- 
ondary to  atherosclerosis  of  the  renal  arteries, 
the  technical  success  rate  is  in  the  range  of  74% 
to  94%.  A cure  or  improvement  in  the  hyperten- 
sion can  be  seen  in  60%  to  70%  of  the  cases.13 
The  use  of  percutaneous  renal  angioplasty  and 
stenting  has  been  reported  by  several  investiga- 
tors as  an  excellent  technique  to  achieve  vessel 
patency  in  patients  with  renal  artery  ostial  le- 
sions (Figure  3).  Some  of  the  advantages  of 


Figure  3.  Same  patient  as  Figure  1.  After  angioplasty  and 
stenting  the  lumen  of  the  right  renal  artery  patent.  Patient 
blood  pressure  was  back  to  normal  limits. 


endovascular  treatment  include  shorter  hospi- 
tal stay,  a lower  cost,  less  invasive  nature  of  the 
procedure,  and  faster  recovery. 

CONCLUSION 

The  evaluation  of  patients  with  renovascular 
hypertension  is  a complex  one.  Clinicians  should 
be  aware  of  clinical  and  physical  findings  that 
suggest  the  presence  of  a correctable  cause  of 
hypertension  and  know  when  to  proceed  with 
further  evaluation.  The  most  appropriate  screen- 
ing study  or  studies  will  depend  on  the  avail- 
ability of  equipment,  experience  of  the  opera- 
tor, and  close  communication  between  the  re- 
ferring physician  and  the  radiologist  or  nuclear 
medicine  physician.  If  any  form  of  intervention 
is  necessary,  close  contact  between  the  interven- 
tionist or  surgeon  is  important  as  well. 

ACKNOWLEDGMENT 

We  would  like  to  express  our  thanks  to  Oscar  F. 
Carbonell,  MD  from  Ormond  Beach  Memorial  Hos- 
pital Florida  for  supplying  the  illustrations  for  this 
article. 

REFERENCES 

1.  Wyngaarden  J,  Smith  L.  Cecil  Textbook  of  Medicine 
18th  edition.  Saunders;  1988:  276. 

2.  Baum  S.  Abrams  Angiography.  4th  edition.  Little 
Brown;  1997:  1250. 

3.  Martin  L.  Technical  considerations  in  the  treatment 
of  renal  fibro-muscular  hyperplasia,  techniques  in 
vascular  and  interventional,  radiology  2;1999:  65- 
73. 

4.  Taylor  A.  Radionucleide  renography:  a personal 
approach.  Semin  Nucl  Med  1999;  29:  102-127. 

5.  Lencioni  R,  Pinto  S,  Napoli  V,  et  al.  Noninvasive 
assessment  of  Renal  artery  stenosis:  current  imag- 
ing protocols  and  future  directions  in  ultrasonog- 
raphy. J Comput  Assist  Tomograph  1999;  23  suppl: 
S95-S100. 

6.  Strandness  DE.  Duplex  imaging  for  the  detection 
of  renal  artery  stenosis.  Am  J Kid  Dis  1994;24:674- 
678. 

7.  Karasch  T,  Rubin  J.  Diagnosis  of  renal  artery  steno- 
sis and  renovascular  hypertension.  Eur  J Ultrasound 
1998;  3 suppl  17:  S27-S39. 

8.  Prokop  M.  Protocols  and  future  directions  in  im- 


J La  State  Med  Soc  VOL  152  May  2000  251 


Cardiovascular  Disease 
in  Louisiana 


aging  of  renal  artery  stenosis:  CT  angiography. 
JCAT  1999;23  suppl:  S101-S110. 

9.  Shoenberg  S,  Martin  P,  Knopp  M,  et  al.  Renal  MR 
angiography,  magn  reson  imaging  clin  North  Am 
1998;  6:351-370. 

10.  Spinosa  D,  Matsumoto  A,  Angle  J,  et  al.  Renal  in- 
sufficiency: usefulness  of  gadodiamine-enhanced 
renal  angiography  to  supplement  C02-enhanced 
renal  angiography  for  diagnosis  of  percutaneous 
treatment.  Radiology  1999;  210:  663-672. 

11.  Meacham  P.  Renovascular  hypertension:  patho- 
physiology, diagnosis,  and  therapeutic  options. 
Compr  Ther  1992;  18:  24-30. 

12.  Humke  U,  Uder  M.  Renovascular  hypertension: 
diagnosis  and  management  of  renal  ischaemia".  B 
JUrol  1999;84:555-569. 

13.  LaBerge  J,  Darcy  M.  SCVIR  Syllabus.  Peripheral  Vas- 
cular Intervention.  Society  of  Cardiovascular  and 
Interventional  Radiology  1994:81. 


Dr  Rivera  is  an  Assistant  Professor  of  Radiology  and  Direc- 
tor of  Interventional  Radiology, Louisiana  State  University 
Health  Science  Center,  Shreveport,  Louisiana. 

Dr  D'Agostino  is  a Professor  of  Radiology  and  Chairman, 
Louisiana  State  University  Health  Science  Center,  Shreve- 
port, Louisiana. 


252  J La  State  Med  Soc  VOL  152  May  2000 


Cardiovascular  Disease 
in  Louisiana 


Thrombolytic  Therapy  for 
Acute  Ischemic  Stroke 

Roger  E.  Kelley,  MD 


Thrombolytic  therapy  with  recombinant  tissue  plasminogen  activator  (rt-RA)  is  now  an  accepted 
treatment  for  acute  ischemic  stroke  if  the  patient  can  be  treated  within  3 hours  of  onset  of 
symptoms,  and  if  the  clinical  presentation  justifies  use  of  the  medication,  and  if  there  are  no 
contraindications  to  the  use  of  rt-PA.  The  non-contrast  CT  brain  scan  is  mandatory  to  rule  out 
an  intracerebral  hemorrhage,  evidence  of  subarachnoid  hemorrhage,  or  significant  evolution  of 
a large  cerebral  infarction.  The  later  the  patient  is  treated,  within  the  3-hour  therapeutic  window, 
the  less  likely  there  is  to  be  clinical  benefit  of  the  treatment  and  the  greater  risk  of  hemorrhagic 
transformation  of  the  cerebral  infarction  with  potentially  catastrophic  consequences.  There  is 
approximately  a 30%  greater  chance  of  full  recovery  from  the  stroke,  at  3 months  out  from  the 
infarct,  with  rt-PA  compared  to  no  rt-PA.  On  the  other  hand,  there  is  a 6.4%  risk  of  symptomatic 
intracerebral  hemorrhage,  within  36  hours,  associated  with  the  use  of  rt-PA  compared  to  a 0.6% 
risk  in  the  placebo  group.  The  greater  the  neurological  deficit  at  the  time  of  presentation  and  the 
greater  the  evolution  of  the  infarct  by  the  admission  CT  brain  scan,  the  greater  the  risk  of 
intracerebral  hemorrhage  complicating  the  use  of  rt-PA. 


Thrombolytic  therapy  is  the  only  interventional 
therapy  presently  available  for  acute  ischemic 
stroke.  The  only  thrombolytic  agent  which 
has  been  released  by  the  FDA  for  use  in  acute  is- 
chemic stroke  is  recombinant  tissue  plasminogen 
activator  (rt-PA).  The  present  use  of  rt-PA  in  stroke 
is  based  upon  a landmark  study  which  was  the  first 
of  its  kind  to  demonstrate  that  an  acute  agent 
could  have  a beneficial  effect  on  stroke  outcome 
if  administered  within  3 hours  of  onset.1  It  is  im- 
portant for  physicians  who  evaluate  and  treat 
patients  with  acute  stroke  to  recognize  that  this 
therapy  is  now  considered  a standard  of  care 
and  should  be  considered  for  patients  who  are 
eligible  for  treatment.  There  are  a number  of  con- 
siderations which  need  to  be  taken  into  account 


prior  to  initiation  of  therapy.  On  the  other  hand, 
failure  to  initiate  treatment  in  an  appropriate  pa- 
tient could  mean  a lost  opportunity  to  prevent 
permanent  neurological  deficit. 

More  recent  studies  have  demonstrated  that 
alternative  thrombolytic  agents  are  of  limited  or 
no  benefit  in  acute  ischemic  stroke.  In  the  case 
of  streptokinase,  for  example,  the  agent  is  asso- 
ciated with  an  unacceptable  risk  of  brain  hem- 
orrhage and  this  risk  negates  any  potential  ben- 
efit.2'5 The  agent  pro-urokinase  has  been  dem- 
onstrated to  have  a favorable  effect  on  outcome 
in  acute  ischemic  stroke,  when  administered 
within  6 hours  of  onset.6  However,  the  risk  of 
intracranial  hemorrhage,  associated  with  neu- 
rological deterioration,  was  10%  and  this  agent 
has  not  been  approved  by  the  FDA. 


J La  State  Med  Soc  VOL  152  May  2000  253 


Cardiovascular  Disease 
in  Louisiana 


INDICATIONS  AND 
CONTRAINDICATIONS  FOR  rt-PA 

rt-PAis  potentially  indicated  for  any  patient  who 
presents  within  3 hours  of  an  acute  ischemic 
stroke  and  in  which  there  is  time  to  assess  the 
results  of  the  non-contrast  CT  brain  scan  and 
some  routine  blood  work.  The  patient  must  have 
some  degree  of  documented  neurological  defi- 
cit and  this  is  usually  based  upon  a score  of  4 or 
more  on  the  National  Institutes  of  Health  (NIH) 
Stroke  Scale.7  Furthermore,  the  patient  should 
not  be  experiencing  progressive  resolution  of 
their  signs  and  symptoms  at  the  time  of  presen- 
tation. One  controversial  issue  is  that  of  informed 
consent.  This  is  especially  pertinent  in  view  of 
the  fact  that  there  is  a 6.4%  risk  of  symptomatic 
intracerebral  hemorrhage,  at  36  hours,  compared 
to  0.6%  in  the  placebo  group.1  Some  physicians 
advocate  some  form  of  informed  consent  in  or- 
der to  document  that  an  effort  was  made  to  in- 
form the  patient  or  family  of  the  potential  for  a 
catastrophic  outcome  with  rt-PA.  On  the  other 
hand,  this  can  lead  to  an  unnecessary  delay  in 
treatment  and  this,  in  and  of  itself,  makes  it  not 
only  less  likely  that  the  patient  will  respond  to 
rt-PA,  but  will  also  have  an  enhanced  risk  of  in- 
tracerebral hemorrhage.  Furthermore,  rt-PA  is 
released  by  the  FDA  for  treatment  of  stroke  in 
eligible  patients  and  it  is  considered  a standard 
of  care.  To  date,  the  implications,  from  a medico- 
legal standpoint,  have  pointed  to  far  greater  li- 
ability in  not  treating  an  eligible  patient  rather 
than  responsibility  for  potential  adverse  effects 
which  are  well  documented  in  both  the  profes- 
sional and  lay  literature.  It  is  advisable,  how- 


ever, for  the  physician  to  document  in  the  records 
that  the  potential  risks,  especially  the  risk  of  in- 
tracerebral hemorrhage,  were  presented  as  ef- 
fectively as  possible  taking  into  account  the 
time  constraints.  On  the  other  hand,  if  the  pa- 
tient does  not  want  to  take  the  risk  of  receiving 
treatment  with  rt-PA,  or  the  family  makes  that 
decision  because  the  patient  is  unable,  then  this 
should  be  carefully  documented  in  the  medical 
records.  Indications  for  the  use  of  rt-PA  in  acute 
stroke  are  summarized  in  Table  1. 

There  are  a number  of  contraindications  to 
the  use  of  rt-PA  and  most  are  in  reference  to  po- 
tential bleeding  complications  (Table  2).  It  is  ex- 
tremely important  for  the  physician  to  adhere 
to  these  contraindications  in  order  to  minimize 
the  risk  of  brain  hemorrhage  as  well  as  to  avoid 
using  this  potentially  dangerous  agent  in  an  in- 
appropriate fashion.  One  issue  of  utmost  impor- 
tance is  the  timing  of  the  symptoms.  A recent 
study  which  looked  at  extension  of  the  window 
of  treatment  to  3 to  5 hours  found  no  benefit.8 
Furthermore,  evolution  of  the  infarct  beyond  the 
accepted  0 to  3 hour  window  has  the  potential 
to  increase  the  risk  of  brain  hemorrhage.  It  is 
important  to  recognize  that  patients  who  wake 
up  with  symptoms  of  stroke  have  be  assumed 
to  have  had  the  onset  around  the  time  when  they 
were  last  awake.  Furthermore,  an  infarction  pat- 
tern that  has  clearly  evolved  on  initial  CT  brain 
scan  raises  questions  about  the  true  onset  of  the 
ischemic  process  as  the  CT  brain  scan  should  be 
either  normal  or  demonstrate  only  sulcal  efface- 
ment  within  3 hours  of  presentation.  Thus,  the 
CT  brain  scan  is  performed  not  only  to  rule  out 


Table  1.  Indications  for  the  Use  of  rt-PA  in  Acute  Stroke 

1 . Evaluation  and  treatment  within  three  hours  of  onset 

2.  Performance  of  a non-contrast  CT  brain  scan  to  exclude  hemorrhage 

3.  Availability  of  routine  laboratory  studies  including  CBC,  platelet  count,  prothrombin  time, 
partial  thromboplastin  time,  blood  glucose,  and  electrolytes 

4.  Fixed  or  progressive  neurological  deficit  with  an  NIH  Stroke  Scale  of  4 or  greater 


254  J La  State  Med  Soc  VOL  152  May  2000 


Cardiovascular  Disease 
in  Louisiana 


Table  2.  Contraindications  to  the  Use  of  rt-PA  in  Acute  Stroke 


1 . Evidence  of  intracranial  hemorrhage  on  pretreatment  evaluation 

2.  Clinical  suspicion  of  subarachnoid  hemorrhage 

3.  Recent  intracranial  surgery,  serious  head  trauma,  or  previous  stroke 

4.  History  of  intracranial  hemorrhage 

5.  Uncontrolled  hypertension  at  the  time  of  treatment,  eg,  systolic  >185  mm  Hg  or  diastolic 
>110  mm  Hg 

6.  Seizure  at  onset  of  stroke 

7.  Active  internal  bleeding 

8.  Presence  of  intracranial  aneurysm,  arteriovenous  malformation,  or  neoplasm 

9.  Bleeding  diathesis  which  can  include  warfarin  therapy  with  a PT  >15  seconds,  heparin 
therapy  within  48  hours  of  presentation  with  an  elevated  PTT,  platelet  count  less  than 
100,000/mm3,  or  clotting  factor  deficiency 


hemorrhage,  but  also  to  evaluate  for  a possible 
evolved  infarction  pattern.  Furthermore,  the  CT 
brain  scan  can  allow  demonstration  of  an  acutely 
thrombosed  middle  cerebral  artery  (Figure). 
Theoretically,  this  would  be  an  ideal  opportu- 
nity for  thrombolytic  therapy  if  the  patient  can 
be  treated  in  time. 

ADMINISTRATION  OF  RT-PA 

rt-PA  is  given  at  a dose  of  0.9  mg/ kg,  up  to  a 
maximum  total  of  90  mg,  with  10%  given  IV  over 
1 minute  with  the  remaining  90%  infused  over  1 
hour.  Antiplatelet  or  anticoagulant  therapy  is  not 
to  be  given  for  at  least  24  hours  after  the  infu- 
sion of  rt-PA.  It  is  recommended  that  a non-con- 
trast CT  brain  scan  be  obtained  24  hours  after 
the  rt-PA  to  assess  for  asymptomatic  intracra- 
nial bleeding.  It  is  recommended  that  the  sys- 
tolic blood  pressure  be  no  higher  than  185  mm 
Hg  and  the  diastolic  blood  pressure  be  no  higher 
than  110  mm  Hg  at  the  time  of  infusion  and  for 
at  least  24  hours  following  the  infusion.  The  need 
for  aggressive  blood  pressure  management  is 
one  of  the  contraindications  for  the  use  of  rt-PA. 
However,  if  blood  pressure  therapy  is  necessary 
to  adhere  to  these  guidelines,  it  is  recommended 
that  one  make  every  effort  to  avoid  a precipi- 
tous drop  in  the  blood  pressure  as  this  can  lead 


to  extension  of  the  infarct  and  worsening  of  the 
outcome.  One  agent  that  has  been  commonly 
used  to  avoid  such  a potential  precipitous  drop 
in  the  blood  pressure  is  labetalol. 

In  light  of  very  real  concerns  about  intra- 
cerebral hemorrhage,  all  treated  patients  should 
be  monitored  in  an  ICU  setting  for  at  least  48 


Figure.  Non-contrast  CT  brain  scan  which  demon- 
strates an  acute  thrombus  within  the  right  middle  cere- 
bral artery  (open  arrow)  as  well  as  an  evolving  infarct 
within  the  distribution  of  the  right  middle  cerebral  ar- 
tery (closed  arrow).  The  finding  of  a hyperdense  middle 
cerebral  artery,  which  is  indicative  of  acute  thrombus 
formation,  is  an  ideal  indicator  of  a possible  response 
to  thrombolytic  therapy  if  the  agent  can  be  given  within 
the  window  of  opportunity  for  treatment. 


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Cardiovascular  Disease 
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hours  following  the  rt-PA  infusion.  If 
deterioration  occurs  during  the  infusion,  the 
infusion  should  be  stopped  immediately  and  a 
repeat  CT  brain  scan  obtained.  It  has  been 
recommended  that  medical  centers  that  use  rt- 
PA  have  a neurosurgeon  available  in  case 
surgical  evacuation  of  an  intracerebral  clot  is 
indicated.  From  a practical  standpoint,  this 
appears  to  be  more  of  a guideline  rather  than  a 
mandate  for  whether  or  not  to  use  rt-PA.  It  does 
not  appear  that  acute  surgical  intervention  is 
going  to  make  that  much  of  a difference  if  a 
clinically  significant  hemorrhagic 
transformation  of  the  infarct  does  indeed  occur. 

EFFICACY  OF  RT-PA 

In  the  NINDS  trial  of  rt-PA,1  patients  treated  with 
rt-PA  had  at  least  a 30%  greater  likelihood  of 
having  minimal  or  no  neurological  disability  at 
3 months  compared  to  placebo.  Mortality  at  3 
months  was  17%  in  the  rt-PA  group  and  21%  in 
the  placebo  group  (P  = .30).  Of  note,  improve- 
ment was  seen  in  all  stroke  subtypes  including 
cardio-embolic  stroke,  large  artery  thrombosis, 
and  small  artery  (lacunar-type)  thrombosis.  At 
1 year,  this  30%  difference  continued  to  be  ob- 
served.9 The  absolute  proportion  with  favorable 
outcome  was  11%  to  13%  greater  in  the  rt-PA 
group.  At  1 year,  the  mortality  rate  was  24%  in 
the  rt-PA  group  compared  to  28%  in  the  placebo 
group  (P  = .29).  The  fact  that  20%  of  patients  es- 
sentially fully  recover  at  3 months,  on  their  own, 
has  implications  for  the  impact  of  interventional 
therapy  on  stroke  outcome.  In  general,  the  more 
minor  the  deficit  at  presentation,  the  greater  the 
likelihood  that  the  patient  will  fully  recover.  Also 
of  note,  there  was  no  difference  in  neurological 
status  at  24  hours  between  the  treated  and  pla- 
cebo group.  This  does  not  necessarily  mean  that 
certain  patients  do  not  have  a rapid  resolution 
of  their  signs  and  symptoms  through  the  use  of 
rt-PA.  The  primary  purpose  of  rt-PA  is  to  lyse 
an  intracranial  vascular  clot.  In  the  NINDS 
study,1  a cerebral  arteriogram  was  not  part  of 
the  protocol  and  this  meant  that  a number  of 
patients  were  entered  into  both  the  treated  and 


placebo  groups  who  did  not  have  a vascular  le- 
sion amenable  to  therapy  with  a thrombolytic 
agent.  Thus,  there  might  well  have  been  a less 
than  expected  efficacy  of  rt-PA  and  an  efficacy 
effect  was  only  clearly  evident  at  3 months  out 
from  treatment.  Of  note,  early  improvement  is 
expected  to  be  a very  favorable  indicator  of  good 
outcome. 

The  fact  that  there  was  a 30%  difference  in 
functional  outcome  at  3 months  indicates  that 
rt-PA  is  not  such  a "wonder  drug"  that  it  has  to 
be  given  in  questionable  cases  or  in  instances 
where  the  patient  or  family  expresses  sincere 
reservations  about  treatment.  The  risk  of  a ma- 
jor intracranial  bleed  is  very  real  and  this  needs 
to  be  factored  into  the  decision  making  process. 
There  are  certain  factors  that  are  associated  with 
an  increased  risk  of  intracranial  bleeding.  The 
two  factors  of  greatest  importance  are  the  sever- 
ity of  neurological  deficit  as  measured  by  the 
initial  NIH  Stroke  Scale  (value  > 22)  and  brain 
edema  which  is  defined  by  acute  hypodensity 
or  mass  effect  on  the  pre-treatment  CT  brain 
scan.10  The  presence  of  one  or  both  of  these  fac- 
tors allows  identification  of  57%  of  patients  who 
will  have  symptomatic  intracranial  hemorrhage. 
Despite  this,  there  is  a greater  chance  of  im- 
proved neurological  outcome  at  3 months  in 
patients  with  these  factors  who  are  treated  with 
rt-PA  than  in  those  with  initial  severe  deficit  who 
are  not  treated. 

POTENTIAL  EXTENSION  OF  THE  USE  OF 
rt-PA  IN  ACUTE  ISCHEMIC  STROKE 

As  mentioned  previously,  an  attempt  to  extend 
the  use  of  rt-PA  for  a 3 to  5 hour  therapeutic  time 
window  following  the  onset  of  ischemic  stroke 
was  unsuccessful.8  In  this  study,  32%  of  the  pla- 
cebo patients  and  34%  of  the  rt-PA  patients  had 
excellent  recovery  at  90  days  (P  = .65).  After  the 
first  10  days  of  treatment,  the  risk  of  symptom- 
atic intracerebral  hemorrhage  was  7.0%  in  the 
treated  group  and  1.1%  in  the  placebo  group  (P 
< .001).  The  European  Cooperative  Acute  Stroke 
Study  (ECASS)  used  a dose  of  rt-PA  of  1.1  mg/ 
kg  with  a 6-hour  time  window.11  This  study  was 


256  J La  State  Med  Soc  VOL  152  May  2000 


Cardiovascular  Disease 
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criticized  because  17.4%  of  subjects  had  major 
protocol  violations.  Some  trends  were  observed 
in  certain  sub-analyses,  which  favored  rt-PA  over 
placebo,  but  the  results  were  not  conclusive.  This 
led  to  the  ECASS  II  study.12  Favorable  outcome 
was  observed  in  54.3%  of  treated  patients  and 
46.0%  of  the  placebo  group  (P  = .024).  Of  inter- 
est, treatment  differences  were  similar  for  both 
the  0 to  3 hour  and  3 to  6 hour  time  intervals  for 
treatment.  Symptomatic  intracranial  hemor- 
rhage was  seen  in  8.8%  of  treated  patients  and 
3.4%  of  placebo  patients. 

In  a open  trial  of  intravenous  rt-PA  in  pa- 
tients with  acute  carotid  territory  stroke,  at  a dose 
of  0.8  mg /kg  with  a treatment  window  up  to  7 
hours,  25  of  43  patients  (58.1%)  had  complete 
recovery  at  90  days.13  Two  patients  died,  includ- 
ing one  with  an  intracerebral  hematoma.  The 
overall  hematoma  rate  was  6.9%.  In  a study  of 
either  intravenous  or  intra-arterial  rt-PA  or  in- 
tra-arterial urokinase  in  acute  basilar  artery  oc- 
clusion,14 recanalization  was  achieved  in  26  of 
51  patients  (51%).  Mortality  was  46%  in  the  re- 
canalization group  and  92%  in  the  non-recanali- 
zation group  (P  = .004).  Of  the  16  survivors,  10 
were  only  minimally  impaired.  The  poor  out- 
come in  vertebrobasilar  occlusive  disease,  with- 
out effective  treatment,  was  also  found  in  a study 
by  Hacke  et  al.15  In  a study  of  65  consecutive 
symptomatic  patients  with  angiographically 
documented  vertebrobasilar  arterial  occlusions, 
treated  with  either  intra-arterial  urokinase  or 
streptokinase  compared  to  antiplatelet  or  anti- 
coagulant therapy,  recanalization  in  the  throm- 
bolytic therapy  group  correlated  significantly 
with  improved  clinical  outcome.  All  patients 
who  did  not  have  recanalization  died  while  14 
of  19  patients  with  recanalization  survived  (P  = 
.000007).  In  a study  by  Egan  et  al,16  using  intra- 
arterial urokinase,  an  improved  outcome  in  basi- 
lar artery  stroke  was  observed  even  with  a mean 
treatment  time  of  12  hours.  A potential  efficacy 
of  thrombolytic  therapy,  beyond  the  presently 
accepted  3-hour  window,  correlates  with  major 
neurological  improvement  seen  within  the  first 
24  hours,  from  time  of  treatment,  as  well  as  with 
the  initial  CT  brain  scan  result.17  The  greater  the 


evolution  of  the  infarct  by  CT  brain  scan,  the 
worst  the  potential  for  any  positive  clinical  re- 
sponse to  thrombolytic  therapy.  Furthermore, 
the  greater  the  degree  of  unstructured 
hvpodensity,  especially  polylobar  and  heteroge- 
neous, on  CT  scan,  the  greater  the  development 
of  reperfusion  which  correlates  with  enhanced 
hemorrhagic  transformation  of  the  infarction. 

SUMMARY 

It  is  important  for  the  physician  who  evaluates 
and  treats  patients  with  acute  ischemic  stroke  to 
have  adequate  knowledge  about  the  indications 
and  contraindications  to  the  use  of  rt-PA.  There 
is  precious  little  time  available  to  assess  the  pa- 
tient, obtain  baseline  laboratory  studies,  and 
obtain  a non-contrast  CT  brain  scan  within  the 
3-hour  window  of  opportunity.  It  is  clear  that 
thrombolytic  therapy  may  make  the  difference 
between  a remaining  lifetime  of  permanent  neu- 
rological deficit  and  essentially  full  recovery  in 
certain  individuals  and  it  is  the  only  agent  pres- 
ently available  which  is  released  by  the  FDA  for 
such  a purpose.  Failure  to  use  it  could  mean  a 
great  missed  opportunity  and  physicians,  pa- 
tients, and  patients'  families  need  to  be  aware 
of  its  availability.  In  one  conference  on  throm- 
bolytic therapy,  a number  of  physicians  polled 
expressed  a reluctance  to  use  rt-PA  because  of 
potential  complications,  on-call  availability,  and 
such.  On  the  other  hand,  a clear  majority  of  these 
same  physicians  wanted  the  treatment  for  them- 
selves if  they  presented  with  an  acute  ischemic 
stroke  within  3 hours  of  onset. 

REFERENCES 

1.  The  NINDS  rt-PA  Study  Group.  Tissue  plasmino- 
gen activator  for  acute  ischemic  stroke.  N Engl  J 
Med  1995;333:1581-1587. 

2.  The  Multi-Center  Acute  Stroke  Trial — European 
Study  Group.  Thrombolytic  therapy  with  streptoki- 
nase in  acute  ischemic  stroke.  N Engl  J Med 
1996;335:145-150. 

3.  Multicentre  Acute  Stroke  Trial — Italy  (MAST-1) 
Group.  Randomized  controlled  trial  of  streptoki- 
nase, aspirin,  and  combination  of  both  in  treatment 
of  acute  ischemic  stroke.  Lancet  1995;346:1509-1514. 


J La  State  Med  Soc  VOL  152  May  2000  257 


Cardiovascular  Disease 
in  Louisiana 


4.  Dorman  GA,  Davis  SM,  Chambers  BR,  et  al.  Strep- 
tokinase for  acute  ischemic  stroke  with  relationship 
to  time  of  administration.  JAMA  1999;276:961-966. 

5.  Yasaka  M,  O'Keefe  GJ,  Chambers  BR,  et  al.  Strep- 
tokinase in  acute  stroke.  Effect  on  reperfusion  and 
recanalization.  Neurology  1998;50:626-632. 

6.  Furlan  A,  Higashida  R,  Wechsler  L,  et  al.  Intra-ar- 
terial pro-urokinase  for  acute  ischemic  stroke.  The 
PROACT  II  Study:  a randomized  controlled  trial. 
JAMA  1999;282:2003-2011. 

7.  Wolfe  CD,  Taub  NA,  Woodrow  BA,  et  al.  Assess- 
ment of  scales  of  disability  and  handicap  in  stroke 
patients.  Stroke  1991;22:1242-1244. 

8.  Clark  WM,  Wissman  S,  Albers  GW,  et  al  for  the 
Atlantis  Study  Investigators.  Recombinant  tissue- 
type  plasminogen  activator  (alteplase)  for  ischemic 
stroke  3 to  5 hours  after  symptom  onset.  The 
Atlantis  Study:  A randomized  controlled  trial. 
JAMA  199;282:2019-2026. 

9.  Kwiatkowski  TG,  Libman  RB,  Frankel  M,  et  al.  Ef- 
fects of  tissue  plasminogen  activator  for  acute  is- 
chemic stroke  at  one  year.  N Engl  J Med 
1999;340:1781-1787. 

10.  The  NINDS  t-PA  Stroke  Study  Group.  Intracerebral 
hemorrhage  after  intravenous  t-PA  therapy  for  is- 
chemic stroke.  Stroke  1997;28:2109-2118. 

11.  The  European  Cooperative  Acute  Stroke  Study 
(ECASS).  Intravenous  thrombolysis  with  recombi- 
nant tissue  plasminogen  activator  for  acute  hemi- 
spheric stroke.  JAMA  1995;274:1017-1025. 

12.  Hacke  W,  Kaste  M,  Fieschi  C,  et  al.  Randomized 


double-blind  placebo-controlled  trial  of  throm- 
bolytic therapy  with  intravenous  alteplase  in  acute 
ischemic  stroke  (ECASS  II).  Lancet  1998;352:1245- 
1251. 

13.  Trouillas  P,  Nighoghossian  N,  Getenet  J-C,  et  al. 
Open  trial  of  intravenous  tissue  plasminogen  acti- 
vator in  acute  carotid  territory  stroke.  Correlations 
of  outcome  with  clinical  and  radiological  data. 
Stroke  1996;27:882-890. 

14.  Brandt  T,  von  Kummer  R,  Muller-Kuppers  M,  et 
al.  Thrombolytic  therapy  of  acute  basilar  artery  oc- 
clusion. Variables  affecting  recanalization  and  out- 
come. Stroke  1996;27:875-881. 

15.  Hacke  W,  Zeumer  H,  Ferbert  A,  et  al.  Intra-arterial 
thrombolytic  therapy  improves  outcome  in  patients 
with  acute  vertebrobasilar  occlusive  disease.  Stroke 
1988;19:1216-1222. 

16.  Egan  R,  Clark  W,  Lutsep  H,  et  al.  Efficacy  of  intra- 
arterial thrombolysis  of  basilar  artery  stroke.  J Stroke 
and  Cerebrovasc  Dis  1999;8:22-2 7. 

17.  Trouillas  P,  Nighoghossian  N,  Derex  L,  et  al.  Throm- 
bolysis with  intravenous  rt-PA  in  a series  of  100 
cases  of  acute  carotid  territory  stroke.  Determina- 
tion of  etiological,  topographic,  and  radiological 
outcome  factors.  Stroke  1998;29:2529-2540. 


Dr  Kelley  is  Professor  and  Chairman  of  the  Department 
of  Neurology  at  Louisiana  State  University 
Health  Sciences  Center  in  Shreveport,  Louisiana. 


258  J La  State  Med  Soc  VOL  152  May  2000 


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Percutaneous  Interventional  Approaches  to 

Diseases  of  the  Aorta 


Dia  Abochamh,  MD  and  Frank  M.  Sheridan,  MD 

Diseases  of  the  aorta  are  prevalent  in  the  Western  world.  Pathophysiology  is  influenced 
by  hypertension,  atherosclerosis,  and  genetic  factors.  The  rupture  of  an  aortic  aneurysm 
or  the  dissection  of  a hematoma  into  the  aortic  wall  causes  significant  mortality  in  this 
country.  Physicians  have  long  wrestled  with  therapies  to  prevent  this  fatal  natural  history. 
It  was  not  until  the  surgical  insertion  of  aortic  grafts  in  the  20th  century  that  effective 
therapy  was  developed.  However,  surgical  mortality  and  morbidity  still  remain  quite 
significant  in  the  higher  risk  population  in  which  these  procedures  often  must  be 
performed.  During  the  1990s,  techniques  and  devices  have  been  developed  which  allow 
placement  of  endovascular  grafts  into  the  aorta  percutaneously,  without  traditional  surgery. 
Two  recently  FDA-approved  devices  require  a team  approach  for  optimal  deployment 
and  care.  In  the  initial  experience,  these  endovascular  devices  appear  to  offer  the  promise 
of  effective  treatment  with  low  procedural  complications. 


It  is  difficult  to  estimate  mortality  due  to  aortic 
disease  in  the  United  States.  While  most  of  the 
250,000  classified  “sudden  deaths”  every  year 
are  due  to  ventricular  arrhythmias,  many  are  also 
caused  by  a rupture  of  an  aortic  aneurysm  or  an  acute 
aortic  dissection.  By  hospital  disease  coding,  over 
16,000  deaths  are  attributed  annually  to  aortic  an- 
eurysms.1 However,  it  is  reported  that  aortic 
dissection  is  the  most  common  fatal  aortic  dis- 
ease, an  even  more  frequent  cause  of  aortic  rup- 
ture than  aneurysms,  yet  hard  numbers  are  dif- 
ficult to  produce.2  Rupture  of  abdominal  aortic 
aneurysm  (AAA)  is  the  tenth  leading  cause  of 
death  for  men  55  years  of  age  and  older.  More 
than  70,000  hospitalizations  each  year  are  due 
to  AAA,  and  more  than  40,000  aortic 
aneurysmectomies  are  undertaken  each  year  to 
try  to  prevent  catastrophic  events.3 


PATHOPHYSIOLOGY 

The  pathophysiology  of  aortic  disease  is  fairly 
straightforward,  but  multifactorial  in  etiology. 
Both  the  insidious  dilation  of  an  aortic  aneu- 
rysm, and  the  sudden  hematoma  advancement 
into  the  aortic  wall  of  dissection  depend  on 
weakness  and  breakdown  of  the  medial  layer  of 
the  aortic  wall.  Advancing  age  alone  causes  a 
fragmentation  of  elastic  fibers  and  loss  of  smooth 
muscle  cell  nuclei  called  medionecrosis.  Collag- 
enous tissue  and  basophilic  ground  substance 
replace  these  lost  medial  components.  A similar 
pathologic  defect,  called  medial  degeneration  (pre- 
viously called  "cystic  medial  necrosis"),  mani- 
fests as  a defect  in  fibrillin,  a constituent  of  elas- 
tin  which  makes  up  most  of  the  medial  layer  of 
the  aortic  wall.  Medial  degeneration  is  the  patho- 


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logic  finding  in  patients  with  Marfan's  syn- 
drome, but  can  be  the  cause  of  aortic  aneurysms 
or  dissections  in  patients  without  other  Marfan 
characteristics  (so-called  annuloaortic  ectasia). 
Finally,  atherosclerosis,  that  most  prevalent  of 
vascular  diseases  in  the  Western  world,  also  af- 
fects the  media  of  the  aorta  and  almost  always 
accompanies  an  aneurysm.  However,  cause  and 
effect  are  less  clear  here  and  still  debated  in  the 
literature.  It  has  been  suggested  that  atheroscle- 
rosis may  be  an  epiphenomenon  rather  than  a 
cause  of  aneurysm.  This  hypothesis  contends 
that  the  altered  hemodynamics  produced  by 
aortic  dilatation  of  any  cause  can  create  athero- 
sclerosis. Indeed,  atherosclerosis  predictably 
forms  on  the  intimal  surface  of  any  aneurysm, 
regardless  of  the  etiology  (dissection,  syphilis, 
Marfan's).  Regardless,  the  same  risk  factors  are 
associated  with  atherosclerosis  and  aortic  dis- 
ease, and  it  is  likely  that  a complex  and  inter- 
related remodeling  process  is  involved  in  the 
synthesis  and  degradation  of  medial  matrix  pro- 
teins.2"4 

Approximately  three  fourths  of  all  aortic 
aneurysms  occur  in  the  abdominal  aorta.  A mi- 
nority of  aneurysms  are  found  in  the  thoracic 
aorta  and  include  the  annuloaortic  ectasia  asso- 
ciated with  Marfan's  syndrome,  the  rare  saccu- 
lar aneurysm  following  unoperated  dissection, 
the  even  rarer  syphilitic  aortitis,  and  the  routine 
"atherosclerotic"  aneurysms.  Thoracoabdominal 
aneurysms  are  those  which  span  the  descend- 
ing thoracic  aorta  and  extend  distally  into  the 
abdominal  aorta.  They  assume  special  signifi- 
cance because  of  the  blood  supply  to  many  ab- 
dominal organs  which  arise  from  this  portion. 
The  majority  of  patients  with  an  aortic  aneurysm 
have  a history  of  hypertension.  The  increased 
wall  stress  caused  by  hypertension  exposes  a site 
of  congenital  or  acquired  medial  weakness.  Once 
begun,  aneurysm  formation  is  promoted  by 
physical  laws  such  as  the  principle  of  LaPlace. 
That  is,  since  the  tension  or  stress  in  the  wall  of 
a vessel  is  directly  related  to  its  intraluminal 
pressure  and  diameter,  expansion  and  rupture 
is  the  natural  history  of  aortic  aneurysms.  Ad- 
ditionally, laminated  thrombus  is  virtually  al- 


ways present  in  these  lesions,  and  can  on  occa- 
sion cause  embolic  problems.2'4 

SURGICAL  THERAPY  FOR 
AORTIC  DISEASE 

Despite  advances  in  noninvasive  imaging  and 
surgical  techniques,  the  diverse  presentations  of 
aortic  disease  can  challenge  the  best  of  clinicians. 
Sir  William  Osier  stated  that  "There  is  no  dis- 
ease more  conducive  to  clinical  humility  than 
aneurysm  of  the  aorta."  As  far  back  as  the  2nd 
century  ad,  surgical  attempts  to  treat  aortic  dis- 
ease were  performed  by  Antyllus,  who  devel- 
oped a technique  to  ligate  the  artery  above  and 
below  the  aneurysm  and  evacuate  the  clot.  In 
the  19th  century,  physicians  attempted  to  pre- 
vent the  rupture  by  ligation  of  the  aorta,  which 
achieved  some  limited  success,  but  at  great  risk 
of  ischemia  to  the  extremities.  Other  physicians 
inserted  permanent  silver  wire  into  aortic  aneu- 
rysms and  some  even  passed  galvanic  current 
through  them  to  induce  thrombosis.  Later,  cel- 
lophane or  other  plastic  films  were  used  to  wrap 
the  aortic  dilatations  to  induce  periarterial  fibro- 
sis. The  early  20th  century  saw  the  development 
of  endoaneurysmorrhaphy,  where  the  diseased 
portion  of  the  vessel  was  excised  and  the  aorta 
repaired.  About  this  same  time  Carrel  and 
Guthrie  began  experimenting  with  different 
techniques  for  homograft  replacements  and 
anastomoses  which  formed  the  basis  of  modern 
aortic  surgery.5 

Currently,  surgery  is  recommended  in  pa- 
tients with  aortic  aneurysms  of  5.5-6  cm  diam- 
eter in  the  thoracic  portion,  or  5 cm  diameter  in 
the  abdominal  aorta.  Similarly,  urgent  surgical 
repair  is  indicated  in  patients  who  present  with 
dissection  or  intramural  hematoma  which  in- 
volves the  ascending  aorta  or  dissections  of  other 
segments  which  compromise  side  branch  blood 
flow  or  are  threatening  rupture.  For  surgery  of 
the  ascending  aorta  and  arch,  total  cardiopul- 
monary bypass  is  required.  In  general,  for  most 
surgical  aortic  repairs,  albumin-coated  Dacron 
grafts  are  sutured  to  relatively  normal  aorta 
proximally  and  distally  from  within  the  aneu- 


260  J La  State  Med  Soc  VOL  152  May  2000 


Cardiovascular  Disease 
in  Louisiana 


rysm  or  dissection  and  important  branch  arter- 
ies are  attached  individually  to  appropriate 
openings  in  the  graft.  The  operative  mortality 
for  thoracic  aneurysm  surgery  ranges  from  10% 
to  15%.  Mortality  is  around  5%  for  AAA  repair, 
and  5%  to  15%  for  procedures  involving  aortic 
dissections.2'4  Of  course,  patients  in  unstable 
condition  or  with  associated  coronary  or  cere- 
brovascular disease  have  greater  operative  risks, 
sometimes  unacceptably  high  (may  exceed 
50%).6 Because  many  patients  with  aortic  disease 
are  elderly  with  serious  concurrent  illnesses 
which  make  them  at  higher  risk,  newer  tech- 
niques have  recently  been  developed  to  treat 
aneurysms  and  dissections  percutaneously  and 
thus,  hopefully,  at  lower  overall  risk.7 

ENDOVASCULAR  GRAFT  DEVICES 

Endoluminal  grafting  offers  an  alternative  ap- 
proach to  care  that  is  potentially  less  invasive 
and  less  risky  than  conventional  operative  aor- 
tic repair.8  The  relatively  high  morbidity  and 
mortality  rates  for  graft  replacement,  especially 
in  the  aging  population,  have  maintained  the 
interest  of  researchers  in  developing  a percuta- 
neous method  of  therapy.  The  first  radiographi- 
cally guided  aortic  graft  implantations  in  ani- 
mal models  were  reported  in  1987  by  Lawrence 
et  al,9  who  used  a chain  of  stainless  steel 
Gianturco  Z-stents  within  a tube  of  woven  poly- 
ester. However,  it  was  not  until  1991  that  Parodi 
et  al10  reported  the  first  clinical  use  in  humans 
of  transfemoral,  endovascular  grafting.  Since 
these  pioneering  efforts,  several  successful  de- 
vices have  been  developed. 

There  are  two  broad  groups  of  endovascular 
grafts  available.  The  "covered"  or  "coated" 
stents  are  single  stent  devices  in  which  the  in- 
ternal or  external  walls  of  the  stent  are  covered 
by  a prosthetic  or  autogenous  graft  barrier  ma- 
terial. These  types  of  covered  stents  were  first 
made  by  suturing  a segment  of  thin  walled 
polytetrafluoroethylene  (PTFE)  graft  to  a Palmaz 
stent  for  use  in  treating  false  aneurysms  in  pe- 
ripheral arteries.  The  other  category  is  termed 
the  "stent-graft".  These  devices  are  traditional 


synthetic  grafts  which  are  fixed  by  a stent  at  ei- 
ther end  or  supported  by  a metal  framework 
throughout  their  lengths. The  stents  (or  metal 
hooks)  are  used  as  anchoring  mechanisms  at 
each  end  of  the  graft  material.  In  this  sense,  the 
stents  act  as  a substitute  for  the  surgical  anasto- 
mosis, leaving  unsupported  graft  material  be- 
tween the  various  attachment  devices.  Full 
length  support  along  the  graft  fabric  with  mul- 
tiple stents  or  a continuous  pattern  of  stent 
wireform  has  been  used  to  avoid  problems  with 
rotation,  twisting,  or  kinking  of  unsupported 
parts.  Endovascular  grafts  may  be  tubular,  ta- 
pered, or  bifurcated  in  configuration.11' 12  In  1999, 
the  FDA  approved  two  stent  designs  (one  of  each 
type  described  above)  for  clinical  use  in  AAA 
repair  and  these  are  shown  in  Figures  1 and  2. 


Figure  1.  This  device  represents  an  example  of  a “cov- 
ered stent”  and  is  built  in  separate  component  parts. 
Courtesy  of  the  Medtronic  Corp. 


J La  State  Med  Soc  VOL  152  May  2000  261 


Cardiovascular  Disease 
in  Louisiana 


IMPLANTATION  TECHNIQUE 

There  are  three  major  components  to  the  implan- 
tation system.  First,  there  is  the  delivery  system 
which  includes  a valve  system,  introducer 
sheath,  and  delivery  catheters.  Secondly,  the 
prosthetic  graft  fabric  must  be  strong  enough  to 
resist  late  deterioration,  but  sufficiently  thin  to 
be  compressed  within  the  narrow  sheath  of  the 
delivery  system.  To  date,  conventional  polyes- 
ter (Dacron)  has  been  preferred.  Trials  have  been 
conducted  on  PTFE,  and  some  companies  are 
now  developing  PTFE  grafts.  Lastly,  the  graft  at- 
tachment systems  must  provide  a blood-tight 
seal  to  exclude  the  aneurysm  from  the  circula- 
tion and  to  anchor  the  endograft  and  prevent 
migration.  The  stent  is  self-expanding  or  balloon 
expanded.  A series  of  hooks  or  barbs  comprise 
the  main  attachment  system.  The  stents  or  metal 
frames  have  been  constructed  from  stainless 
steel,  nitinol,  or  elgiloy.  Nitinol  has  the  advan- 
tage of  a thermal  memory  in  addition  to  self- 
expanding properties. 

Endovascular  graft  placement  can  be  per- 
formed in  the  cardiac  catheterization  laboratory 
or  in  the  operating  room.  Until  recently  general 
anesthesia  was  required,  but  local  anesthesia  has 
been  utilized  in  the  past  year  by  some  centers.  A 
team  approach  consisting  of  cardiovascular  sur- 
gery, anesthesiology,  interventional  radiology, 
and  interventional  cardiology  is  highly  recom- 
mended for  optimal  results  and  safety. 

The  femoral  or  distal  iliac  artery  is  surgically 
exposed.  Intravenous  heparin  is  injected  and  a 
6 Fr  pigtail  catheter  is  inserted  over  a .035  inch 
guide  wire  to  the  level  of  the  left  subclavian  ar- 
tery. Fluoroscopy,  often  in  conjunction  with 
transesophageal  ECHO,  is  used  to  confirm  the 
position  of  the  guidewire  in  the  true  lumen  of 
the  aorta.  The  sheath  with  the  stent,  a pusher, 
and  a deflated  large-bore  latex  balloon  are  in- 
troduced. The  compressed  stent  is  advanced  to 
the  site  of  the  diseased  aortic  segment  (aneurysm 
or  dissection),  under  fluoroscopy.  Before  the 
stent  is  deployed,  many  operators  titrate  the  sys- 
tolic blood  pressure  to  50  mm  Hg  with  nitroprus- 
side,  esmolol,  and  nitrates.  When  blood  circula- 


tion is  attenuated  through  the  false  lumen,  the 
stent  is  expanded.  After  the  stent  is  fully  ex- 
panded and  there  is  no  flow  into  the  false  lu- 
men, the  infusions  are  discontinued.  No  addi- 
tional heparin  or  antiplatelet  therapy  is  admin- 
istered after  the  completion  of  the  procedure. 

When  the  iliac  arteries  are  also  involved, 
implantation  of  a bifurcated  graft  requires  ad- 
ditional steps.  To  date,  two  main  techniques  have 
been  used.  Single  piece  bifurcated  endovascular 
grafts  are  introduced  into  the  aorta  with  one  limb 
(the  contralateral  limb)  being  manipulated  into 
position  by  guide  wires  and  pull-wires  directed 
across  the  aortic  bifurcation.  This  type  of 
endovascular  stent  eliminates  the  potential  for 
leak  or  graft  failure  (Figure  2).  Grafts  composed 


Figure  2.  This  device  represents  an  example  of  a “stent- 
graft”  and  is  built  in  a single  bifurcated  piece.  Courtesy 
of  the  Guidant  Corp. 


262  J La  State  Med  Soc  VOL  152  May  2000 


Cardiovascular  Disease 
in  Louisiana 


of  separate  component  parts  are  telescoped  and 
overlapped  within  the  aorta  or  the  iliac  artery 
to  construct  the  bifurcated  configuration.  This 
allows  the  second  iliac  limb  to  be  inserted 
through  the  contralateral  femoral  artery  access. 
These  "stents  in  pieces"  carry  more  potential  for 
leakage,  disconnection,  or  stenosis  at  graft  over- 
lap zones.  The  healing  processes  after  the  de- 
ployment of  the  stent  graft  are  not  yet  clear,  es- 
pecially at  the  point  where  fixation  is 
achieved.6, 13 

COMPLICATIONS  OF 
ENDOVASCULAR  GRAFTING 

As  in  traditional  aortic  surgery,  stroke,  paraple- 
gia or  paraparesis,  myocardial  infarction,  respi- 
ratory complications,  and  endovascular  leak  are 
all  possible  complications  in  this  high-risk  pa- 
tient population.  Causes  of  stroke  include  cath- 
eter or  sheath  manipulations  in  the  aortic  arch 
and  ascending  aorta,  and  excessive  anticoagu- 
lation. A major  unresolved  issue  is  the  potential 
for  leak  around  the  endovascular  stent-graft  into 
the  aneurysm  sac  (so-called  "endoleak").  One 
type  of  endoleak  is  related  to  an  inadequate  seal 
at  the  proximal  or  distal  segments  of  the 
endoprosthesis.  Another  is  caused  by  retrograde 
branch  flow  through  patent  inferior  mesenteric 
or  lumbar  arteries.  Spontaneous  thrombosis  has 
been  noted  in  25%  of  the  cases  of  endoleak.  Ad- 
vances in  the  technique  and  improved  device 
design  appear  to  have  diminished  the  incidence 
of  the  former  type  of  endoleak  to  approximately 
5%.  Coil  embolization  is  an  effective  treatment 
in  almost  all  of  the  cases.14  In  the  absence  of 
endoleak,  several  studies  have  demonstrated 
that  aneurysm  diameter  decreases  an  average 
of  5 to  9 mm/ y after  endografting.  The  hospital 
mortality  rate  for  endovascular  stent  grafting  of 
descending  thoracic  aneurysms  was  reported  as 
9%  from  the  Stanford  University  experience  be- 
tween 1992  and  1997.6  Another  recent  study  from 
Germany  experienced  a mortality  rate  of  0%  for 
endovascular  graft  placement  in  aortic  dissec- 
tions, compared  to  33%  for  a surgically  treated 
group  of  patients.13  Thus,  the  early  clinical  ex- 


perience with  these  new  devices  appears  quite 
favorable  and  promising. 

CONCLUSIONS 

Aortic  disease  has  vexed  physicians  for  millen- 
nia and  will  continue  to  be  a major  cause  of 
mortality  and  morbidity  well  into  the  21st  cen- 
tury. This  is  especially  true  in  the  United  States 
where  the  percentage  of  the  population  over  the 
age  of  65  will  increase  from  its  current  level  of 
13%  to  over  20%  by  2030.  Hopefully,  some  of  our 
other  risk  factors,  such  as  cigarette  use,  hyper- 
tension, and  hypercholesterolemia  will  decline 
over  that  time.  Nevertheless,  treating  aortic  an- 
eurysms and  dissections  will  continue  to  be 
tricky  business,  as  they  are  difficult  to  diagnose 
and  often  catastrophic  in  their  presentation.  Sur- 
gical techniques  for  repair  of  the  aorta  have  pro- 
vided longer  and  improved  lives  for  many  pa- 
tients. However,  some  patients'  risk  factor  pro- 
files or  concurrent  illnesses  will  make  operative 
risks  high.  The  potential  benefits  of  percutane- 
ous endovascular  grafting  include  reduction  in 
perioperative  and  long-term  mortality,  fewer 
complications,  shorter  recovery  time,  and  lower 
health  care  costs.  Definitive  evaluation  of 
endovascular  grafting  for  aortic  aneurysms  and 
dissections  awaits  the  long-term  results  of  sev- 
eral ongoing,  prospective,  controlled,  multicen- 
ter trials. 

REFERENCES 

1.  American  Heart  Association.  2000  Heart  and  Stoke 
Statistical  Update.  Dallas,  Tex:  American  Heart  As- 
sociation; 2000. 

2.  Braunwald  E.  Heart  Disease , 5th  edition.  Philadel- 
phia: W B Saunders;  1997:1546-1581. 

3.  Alexander  RW,  Schlant  RC,  Fuster  V.  Hurst's  The 
Heart , 9th  edition.  New  York:  McGraw-Hill; 
1998:2461-2482. 

4.  Topol  EJ.  Textbook  of  Cardiovascular  Medicine.  Phila- 
delphia and  New  York:  Lippincott  - Raven; 
1998:2519-2539. 

5.  Cooley  DA.  Aortic  aneurysm  operations:  past, 
present,  and  future.  Ann  Thorac  Surg  1999;67:1959- 
1962. 

6.  Dake  MD,  Kato  N,  Mitchell  RS,  et  al.  Endovascular 
stent-graft  placement  for  the  treatment  of  acute 


J La  State  Med  Soc  VOL  152  May  2000  263 


Cardiovascular  Disease 
in  Louisiana 


aortic  dissection.  N Engl  J Med  1999;340:1546-1552. 

7.  Kouchoukos  NT,  Dougenis  D.  Surgery  of  the  tho- 
racic aorta.  New  Engl  J Med  1997;336:1876-1888. 

8.  Scott  R,  Miller  C,  Dake  M,  et  al.  Thoracic  aortic 
aneurysm  repair  with  an  endovascular  stent  graft: 
the  "First  Generation".  Ann  Thor  Surg  1999;67:1971- 
1974. 

9.  Lawrence  DD,  Charnsangavej  C,  Wright  KC.  Per- 
cutaneous endovascular  graft:  experimental  evalu- 
ation. Radiology  1987;163:357-360. 

10.  Parodi  JC,  Palmaz  JC,  Barone  HD.  Transfemoral 
intraluminal  graft  implantation  for  abdominal  aor- 
tic aneurysm.  Ann  Vas  Surg  1991;5:491-499. 

11.  May  J,  White  GH,  Harris  JP.  Devices  for  aortic  an- 
eurysm repair.  Surg  Clin  North  Am  1999;79:507-527. 

12.  Fann  JI,  Miller  DC.  Endovascular  treatment  of  de- 
scending thoracic  aortic  aneurysms  and  dissections. 
Surg  Clin  North  Am  1999;79:551-574. 

13.  Nienaber  CA,  Rossella  F,  Gunnar  L,  et  al.  Nonsur- 
gical  reconstruction  of  thoracic  aortic  dissection  by 
stent-graft  placement.  N Engl  J Med  1999;340:1539- 
1545. 

14.  Matsumura  JS,  Pearce  WH.  Early  clinical  results 
and  studies  of  aortic  aneurysm  morphology  after 
endovascular  repair.  Surg  Clin  North  Am  1999; 
79:529-539. 


Dr  Abochamh  is  a senior  fellow  in  cardiology  at 
Eouisiana  State  University  Health  Sciences  Center  in 

Shreveport,  Eouisiana. 

Dr  Sheridan  is  an  interventional  cardiologist  at 
Eouisiana  State  University  Health  Sciences  Center 
in  Shreveport,  Eouisiana.  He  is  on  faculty  at  the  ESU 
School  of  Medicine  as  a Professor  of  Medicine,  and  is  a 
member  of  the  Board  of  Directors  of  the  Southeast  Affiliate 
of  the  American  Heart  Association. 


264  J La  State  Med  Soc  VOL  152  May  2000 


This  month \ we  celebrate  our  10th  anniversary. 


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June  2000 


3-7  Association  for  the  Advancement  of 
Medical  Instrumentation  2000 
Conference  & Expo.  San  Jose,  Cal. 
Contact  the  AAM I at  (703)  525-1424  or  visit 
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9-10  The  IPA  Association  of  America,  2nd 
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Breakaway.  Point  Clear,  Al.  Contact  Anne 
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268  J La  State  Med  Soc  VOL  152  May  2000 


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Pathologic  Disruption  of  the  Distal  Biceps  Brachii  Tendon  by  Synovial  Sarcoma 


Hypertension  Treatment  in  the  New  Millennium:  The  Importance  of  Controlling 
Systolic  Blood  Pressure  and  the  Pulse  Pressure 

Pathobiologicai  Determinants  of  Atherosclerosis  in  Youth  (PDAY) 
Cardiovascular  Specimen  and  Data  Library 


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MRA  is  a non-invasive  test  and  requires 
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ESTABLISHED  1844.  Owned  and  edited  by  the 
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Of  the  Louisiana  State  Medical  Society 


^ticles 


Stuart  A.  Chalew,  MD  286 

Michael  T.  Duplechain,  BS  289 

Morgan  P.  Lorio,  MD 
Richard  G.  Lastrapes,  MD 

F.  Gilbert  McMahon,  MD  293 

Edward  Frohlich,  MD 


Arthur  W.  Zieske,  MD  296 
Gray  T.  Malcom,  PhD 
Jack  P.  Strong,  MD 


EPARTMEf 


272 

Jorge  I.  Martinez-Lopez,  MD  273 

David  A.  Godin,  MD  276 

Kimsy  H.  Rodriguez,  MD 
Foster  Hebert,  MD 

Harold  Neitzschman,  MD  281 

Sanjay  M.  Patel,  MD 
Jessica  Borne,  MD 

Gustavo  A.  Colon,  MD  283 

303 

305 


Can  We  Prevent  Type  1 Diabetes? 

Pathologic  Distruption  of  the  Distal  Biceps 
Brachii  Tendon  by  Synovial  Sarcoma 


Hypertension  Treatment  in  the  New 
Millennium:  The  Importance  of  Controlling 
Systolic  Blood  Pressure  and  the  Pulse 
Pressure 

Pathobiological  Determinants  of 
Atherosclerosis  in  Youth  (PDAY) 
Cardiovascular  Specimen  and  Data  Library 


INFORMATION  FOR  AUTHORS 

ECG  OF  THE  MONTH 
Nowhere  to  Go 

OTOLARYNGOLOGY/HEAD  & NECK 
SURGERY  REPORT 
Tracheal  Stenosis 

RADIOLOGY  CASE  OF  THE  MONTH 
Cerebrovascular  Accident 

THE  JOURNAL  150  & 100  YEARS  AGO 
June  1850  and  1900 

CALENDAR 

CLASSIFIED  ADVERTISING 


J La  State  Med  Soc  VOL  152  June  2000 


271 


Information  for  Authors 


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1 . Brush  JE  Jr,  Cannon  RO  III,  Schenke  WH,  et  al.  Angina  due  to  coro- 
nary microvascular  disease  in  hypertensive  patients  without  left  ven- 
tricular hypertrophy.  N Engl  J Med  1988;319:1302-1307. 

2.  Hajdu  SI.  Pathology  of  Soft  Tissue  Tumors.  Philadelphia,  Pa:  Lea  & 
Febiger;  1979:60-83. 

3.  Robinson  BEL  Lactic  acidemia.  In:  Scriver  CR,  Beaudet  AL,  Sly  WS, 
et  al  (editors).  The  Metabolic  Basis  of  Inherited  Disease , 6th  edition. 
New  York:  McGraw-Hill;  1989:869-888. 

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Editor,  Journal  of  the  Louisiana  State  Medical  Society 
6767  Perkins  Rd. 

Baton  Rouge,  LA  70808 


272  J La  State  Med  Soc  VOL  152  June  2000 


ECG  of  the  Month 


Nowhere  To  Go 

Jorge  I.  Martinez-Lopez,  MD 


A 50-year-old  woman  presented  to  the  hospital  with  a recent  history  of  recurrent,  brief 
episodes  of  dizziness.  The  rhythm  strip  shown  below,  limb  lead  II,  was  recorded  before  she 
was  hospitalized.  Medications  included  digitalis  and  antihypertensives. 


What  is  your  diagnosis? 
Elucidation  begins  on  page  274. 


J La  State  Med  Soc  VOL  152  June  2000  273 


ECG  of  the  Month 
Presentation  is  on  page  273. 

DIAGNOSIS  - Second-degree  AV  block 

Sinus  rhythm,  at  68  times  a minute,  is  present, 
with  narrow  QRS  complexes  consistent  with 
normal  intraventricular  conduction.  T-waves  are 
upright  and  the  QT  interval  is  normal. 

At  first  glance,  it  is  obvious  that  cardiac  cycles 
are  occurring  in  groups  separated  by  pauses, 
whose  duration  is  shorter  than  two  cycles.  The 
reason  for  this  " group  beating"  needs  to  be  ex- 
plored further.  Although  every  QRS  complex  is 
preceded  by  a P wave,  not  every  P wave  is  ac- 
companied by  a QRS  complex.  In  the  top  panel, 
for  example,  the  second,  seventh,  and  ninth  P 
waves  are  not  followed  by  QRS  complexes.  Simi- 
larly, the  third,  sixth,  and  tenth  P waves  in  the 
lower  panel  are  not  followed  by  QRS  complexes 
either. 

Failure  of  some  of  the  supraventricular  im- 
pulses to  cross  the  AV  junction  and  bundle  of 
His  and  to  depolarize  the  ventricular  muscula- 
ture is  due  to  intermittent  AV  block.  Two  disor- 
ders in  which  such  an  intermittent  phenomenon 
may  occur  are  second-degree  AV  block  and 
pseudo-second-degree  AV  block  caused  by  non- 
conducted  (blocked)  premature  atrial  impulses. 
To  differentiate  these  two  arrhythmias,  further 
analysis  of  the  tracing  is  necessary.  The  blocked 
P waves  are  similar  in  morphology  and  polarity 
to  the  sinus  P waves.  Moreover,  P-P  intervals, 
including  the  cycles  with  blocked  P waves,  are 
constant  and  equal.  These  findings  argue  against 
the  possibility  that  the  observed  pauses  and  the 
blocked  P waves  are  due  to  non-conducted  pre- 
mature atrial  impulses. 

Second-degree  AV  block  is  manifested  on  the 
surface  ECG  in  several  ways:  Mobitz  type  I and 
type  II  AV  block;  persistent  2:1  AV  block;  and 
advanced  AV  block.  Examination  of  the  tracing 
discloses  variable  AV  ratios:  5:4;  2:1;  4:3;  and  3:2. 
Accordingly,  neither  persistent  2:1  AV  block  nor 
advanced  second-degree  AV  block  is  a viable 
ECG  diagnosis. 


The  other  two  categories  of  second-degree 
AV  block  are  Mobitz  type  I and  type  II.  Type  I 
characteristically  shows  the  Wenckebach  pat- 
tern, in  which  PR  intervals  lengthen  progres- 
sively until  a P wave  is  blocked.  Because  the 
block  occurs  at  the  junctional  level,  QRS  com- 
plexes are  narrow,  unless  bundle  branch  block 
was  present  before  the  appearance  of  type  I 
block.  As  a rule,  type  I block  is  clinically  benign 
and  reversible,  either  spontaneously  or  after 
modification  or  elimination  of  its  cause. 

Type  II  block,  on  the  other  hand,  represents 
a more  severe  and  irreversible  pathology.  It  is 
characterized  by  constant  and  identical  PR  in- 
tervals in  successive  cardiac  cycles  before  the 
blocked  P wave.  In  contrast  to  type  I,  block  in 
type  II  occurs  in  the  distal  intraventricular  con- 
duction system.  For  this  reason,  QRS  complexes 
in  type  II  block  are  nearly  always  wide,  and  usu- 
ally display  a pattern  of  either  right  or  left  bundle 
branch  block. 

The  distinction  between  type  I and  type  II 
second-degree  AV  block,  therefore,  can  be  facili- 
tated by  measurement  of  PR  intervals.  The 
length  of  the  PR  intervals  is  variable  in  the 
rhythm  strip.  For  example,  PR  intervals  — be- 
ginning with  the  third  P wave  in  the  top  panel 
— progressively  increase  from  0.16  sec,  to  0.32 
sec,  to  0.36  sec,  and  finally  to  0.38  sec,  before  the 
blocked  P wave  that  ends  that  sequence;  the  larg- 
est increment  in  the  PR  intervals  occurred  be- 
tween the  first  and  second  PR  intervals.  Note 
also  that  increments  by  which  PR  intervals  in- 
creased were  progressively  smaller  during  the 
sequence.  Similar  observations  can  be  made  in 
the  remaining  sequences  in  both  panels,  except 
for  the  single  occurrence  of  a 2:1  AV  ratio  (eighth 
and  ninth  P waves  in  top  panel).  Following  the 
blocked  P wave,  the  PR  interval  shortens  to  its 
normal  value,  and  the  sequence  is  repeated 
again. 

To  sum  up,  it  appears  that  the  first  P wave  of 
every  sequence  has  no  problem  getting  through 
the  AV  junction  and  distal  conducting  system 
and  reaches  and  depolarizes  the  ventricles.  Sub- 
sequent P waves,  on  the  other  hand,  find  it  in- 
creasingly difficult  to  cross  the  gateway  to  the 


274  J La  State  Med  Soc  VOL  152  June  2000 


ventricles  but  depolarize  them  successfully. 
Eventually,  the  last  P wave  of  every  sequence 
has  nowhere  to  go  and  is  not  conducted  down- 
grade. The  ECG  pattern  in  this  tracing  is  one  of 
second-degree  AV  block  of  the  Wenckebach  type 
(Mobitz  type  I). 

Mobitz  type  I second-degree  AV  block  may 
be  found  in  perfectly  healthy  individuals,  as  well 
as  in  patients  with  digitalis  toxicity  and  in  acute 
inferior  wall  infarction.  The  block  may  subside 
during  ECG  exercise  testing,  when  catechola- 
mine levels  rise,  or  following  the  administration 
of  intravenous  atropine.  Because  type  I AV  block 
is  relatively  benign  and  transient,  permanent 
cardiac  pacing  is  not  indicated. 

Although  the  patient  did  not  present  with 
clear-cut  digitalis  toxicity,  it  was  felt  that  digi- 
talis therapy  was  the  cause  of  the  Mobitz  type  I 
block.  The  digitalis  dose  was  reduced,  the  con- 
duction abnormality  and  episodes  of  dizziness 
disappeared,  and  pacemaker  implantation  was 
avoided. 


Dr  Martinez-Lopez  is  a specialist  in  cardiovascular 
diseases  affiliated  with  the  Cardiology  Service,  Depart- 
ment of  Medicine,  Texas  Tech  University  Health  Sciences 
Center  and  Thomason  General  Hospital  in  El  Paso,  Texas. 


GACHASSIN 

L A W • F I R M 

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of  the  Health  Care  Industry 

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effective  legal  services  to  diverse  clients  in  the 
health  care  industry.  Our  attorneys  are  experienced 
in  transactional  and  corporate  matters,  managed 
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J La  State  Med  Soc  VOL  152  June  2000  275 


Otolaryngology/ 

u erv 


Tracheal  Stenosis 

David  A.  Godin,  MD;  Kimsy  H.  Rodriguez,  MD;  Foster  Hebert,  MD 


While  still  an  uncommon  cause  of  airway  obstruction,  the  incidence  of  tracheal  stenosis  in 
adults  has  increased  with  the  use  of  assisted  ventilation.  The  etiology,  diagnosis,  and 
treatment  of  tracheal  stenosis  are  discussed.  Special  attention  is  paid  to  post-intubation 
tracheal  stenosis  and  to  tracheal  resection  as  its  most  successful  treatment  option. 


Tracheal  stenosis,  while  uncommon,  is  an 
important  and  largely  curable  cause  of 
upper  airway  obstruction.  Historically, 
tracheal  stenosis  was  more  commonly  discussed 
as  it  related  to  congenital  stenosis  in  the  pediatric 
population.  With  prolonged  assisted  ventilation 
through  tracheostomy  and  endotracheal  intu- 
bation, the  incidence  of  adult  cases  has  increased. 
Early  recognition  and  correct  treatment  are 
important  in  ensuring  a successful  long-term  cure. 

ETIOLOGY 

In  children,  the  most  common  causes  of  tracheal 
stenosis  are  congenital  malformations,  including 
complete  tracheal  rings  and  vascular  slings.  In 
adults,  the  most  common  cause  of  tracheal 
stenosis  is  iatrogenic  postintubation  injury,  due 


to  the  increasing  number  of  patients  receiving 
respiratory  support  by  either  tracheostomy  or 
laryngotracheal  intubation.1  The  endotracheal  or 
tracheostomy  tube  can  produce  a variety  of 
injuries  progressing  to  stenosis.  Laryngotracheal 
tubes  can  cause  laryngeal  and  subglottic  injury, 
as  well  as  tracheal  injury  at  the  level  of  the  cuff. 
The  use  of  high  pressure  cuffs  or  inappropriate 
overinflation  of  low  pressure,  high  compliance 
cuffs  used  today  can  produce  a circumferential 
pressure  injury  of  the  trachea.  Repetitive  move- 
ment of  the  cuff  against  the  tracheal  mucosa  from 
mechanical  ventilation  can  cause  abrasion  in- 
juries to  the  lumenal  surface.  The  resulting  ne- 
crosis can  eventually  lead  to  circumferential 
scarring.  This  injury  can  occur  in  as  little  as  48 
hours  of  endotracheal  intubation.  Tracheostomy 


276  J La  State  Med  Soc  VOL  152  June  2000 


tubes,  like  laryngotracheal  tubes,  can  result  in 
injuries  at  the  cuff  site;  however,  the  site  of  injury 
is  usually  lower  than  with  a laryngotracheal 
tube.  Tracheostomy  tubes,  unlike  laryngotrach- 
eal tubes,  can  produce  stenoses  at  the  level  of 
the  stoma  from  granulation  tissue,  erosion,  and 
scarring.  The  eventual  cicatricial  injury  com- 
monly forms  an  anterior /lateral,  or  "A"  shaped, 
stenosis.  This  type  of  injury  is  more  often  seen 
in  patients  with  prolonged  mechanical  ventil- 
ation through  a tracheostomy  tube  because  of 
the  leverage  exerted  against  the  tracheal  wall  by 
the  ventilator  tubing.1'2  Tracheal  injury  and  sten- 
osis are  also  possible  at  the  contact  point  of  the 
tip  of  the  tracheostomy  tube  with  the  tracheal 
wall.  The  anterior  angle  of  the  tip  can  cause 
granulation  tissue  formation,  erosion,  and  even 
a tracheoinnominate  fistula.  Tracheomalacia  is 
another  consequence  of  tracheal  intubation  and 
most  commonly  occurs  between  the  stoma  and 
the  level  of  the  tracheostomy  cuff  (Figure).2 

Less  common  causes  of  tracheal  stenosis 
include  a wide  variety  of  inflammatory,  infec- 
tious, neoplastic,  traumatic,  iatrogenic,  and  idio- 
pathic processes.  Obstruction  of  the  trachea  by 
primary  or  secondary  neoplastic  lesions  is 
occasionally  seen.  The  most  common  primary 
tracheal  neoplasm  is  squamous  cell  carcinoma, 
and  the  most  common  secondary  neoplastic 
lesion  is  a thyroid  malignancy.  Inflammatory 
etiologies  consist  of  such  disorders  as  Wegener's 
granulomatosis,  polychondritis,  and  amyloido- 
sis. Infections,  like  tuberculosis  and  diphtheria, 
and  traumatic  injuries,  such  as  chemical  burns, 
can  rarely  cause  tracheal  obstruction.  Idiopathic 
tracheal  stenosis  is  an  entity  characterized  by  a 
fibrous  circumferential  stenosis  of  a 2 to  3 cm 
segment  of  the  subglottic  airway  with  no  known 
cause.3 

PRESENTATION 

Tracheal  stenosis  is  still  relatively  uncommon; 
however,  the  diagnosis  should  be  suspected  in 
any  patient  with  a history  of  prior  intubation  or 
tracheostomy  within  the  past  2 years  who 
displays  pulmonary  symptoms.  Most  patients 
become  symptomatic  when  the  tracheal  lumen 


is  reduced  by  30%  to  40%.  Usually,  tracheal 
stenosis  will  present  with  evidence  of  upper 
airway  obstruction  within  2 months  of  extu- 
bation;  however,  this  can  be  delayed  up  to  2 
years  and  possibly  longer.  Patients  with  mild 
stenosis  may  present  with  recurrent  pneumonia 
or  progressive  dyspnea  on  exertion  and  are  often 
misdiagnosed  with  adult-onset  asthma.  These 
symptoms  can  be  easily  overlooked  in  the 
patient  with  chronic  obstructive  pulmonary  dis- 
ease. With  increasing  degrees  of  stenosis,  pa- 
tients may  exhibit  wheezing  or  stridor  with 
minimal  activity.  Stridor  is  not  usually  seen  until 
the  tracheal  lumen  is  less  than  5 mm.4  Cyanosis 
most  commonly  occurs  as  a late  sign. 

DIAGNOSIS 

Endoscopic  assessment  (laryngoscopy  or  bron- 
choscopy) and  plain  airway  films  (chest  films, 
lateral  neck  soft  tissue  films,  filtered 
radiographs,  tomograms)  are  the  gold  standard 
in  order  to  work  up  suspected  tracheal  stenosis.5 
Fluoroscopy  can  be  helpful  at  times  in  demon- 
strating malacia  and  vocal  cord  function. 
Computed  tomography  is  often  done;  however, 
most  feel  that  it  is  not  very  useful  except  in  cases 
of  neoplasia.1,2'4'5  It  is  of  paramount  importance 
that  the  larynx  be  evaluated  thoroughly,  because 
a successful  tracheal  repair  depends  on  a 
functional  larynx.  If  the  larynx  is  impaired,  the 
laryngeal  repair  becomes  mandatory  prior  to  or 
at  the  same  time  as  the  tracheal  stenosis  repair.4 
Bronchoscopy  can  be  done  prior  to  or  at  the  same 
time  as  the  definitive  procedure;  however,  it 
should  be  done  very  carefully  through  any 
stricture  due  to  the  tenuous  nature  of  the 
comprised  airway.2  Different  sizes  of  rigid 
bronchoscopes  should  be  available  in  the  event 
of  an  airway  emergency.  Flexible  brochoscopy, 
although  valuable  to  look  at  the  awake  airway, 
can  cause  irritation  and  brochospasm  in  an 
already  compromised  airway.  During  endo- 
scopy, one  should  carefully  evaluate  the  nature 
of  the  stenosis  (granulation  tissue,  scar,  or  such), 
the  location  of  the  stenosis  (glottic,  subglottic, 
tracheal),  the  length  of  the  stenosis,  and  its 
diameter.1  While  pulmonary  function  tests  are 


J La  State  Med  Soc  VOL  152  June  2000  277 


not  necessary  in  the  diagnosis  and  treatment  of 
tracheal  stenosis,  they  show  a decreased  flow 
pattern  consistent  with  upper  airway 
obstruction. 

TREATMENT 

Tracheal  resection  with  primary  end-to-end 
anastomosis  is  the  most  common  treatment 
option  for  tracheal  tumors  and  isolated  stenotic 
segments  of  less  than  50%  of  the  tracheal  length. 
Alternative  procedures,  such  as  laser  vapor- 
ization, dilation,  and  stenting  are  largely  re- 
served for  lesions  less  than  1 cm  in  length  or  for 
palliative  care  in  inoperable  cases  such  as 
patients  who  are  ventilator  dependent,  patients 
with  dysphagia  resulting  in  aspiration,  and 
patients  with  greater  than  50%  tracheal  length 
involvement.  T-tubes  and  tracheotomies  are 
other  less  desirable  but  often  effective  options 
for  patients  who  are  not  candidates  for  tracheal 
resection.6 

Performed  properly,  tracheal  resection  offers 
the  best  long-term  results  reaching  a success  rate 
greater  than  90%  in  most  studies.  As  stated 
above,  a meticulous  preoperative  and  intraoper- 
ative assessment  of  the  stenosis  is  necessary. 
Preoperative  infections  and  inflammation  should 
be  treated  prior  to  the  definitive  procedure.The 
contraindications  to  tracheal  resection  include 
the  inability  to  voluntarily  cough  or  expectorate, 
intractable  aspiration,  moderate  or  severe  chron- 
ic respiratory  insufficiency,  and  long  or  bifocal 
stenoses.  The  key  to  a successful  tracheal 
resection  is  the  creation  of  a low-tension  ana- 
stomosis. This  is  accomplished  by  mobilizing  the 
trachea  while  preserving  laryngeal  function, 
tracheal  blood  supply,  and  deglutition.  Several 
operative  tech-niques  have  been  used  to  attain 
this  result.6 

Most  cases  of  tracheal  stenosis  are  resected 
using  a low  cervical  collar  incision.  Additional 
exposure  is  rarely  needed  but  can  be  obtained 
by  an  upper  sternal  division.  After  raising  sub- 
platysmal  flaps,  the  strap  muscles  are  bluntly 
dissected  and  retracted  laterally.  The  thyroid 
isthmus  is  then  bisected  and  the  thyroid  is 


dissected  from  the  trachea.  The  pretracheal  fascia 
is  then  bluntly  dissected  from  the  cricoid  to  the 
carina.  The  recurrent  laryngeal  nerves  are  not 
identified  during  the  procedure,  but  are  pro- 
tected by  dissecting  close  to  the  tracheal  wall. 
Limiting  the  extent  of  circumferential  dissection 
of  the  trachea  to  no  more  than  2 cm  proximal 
and  distal  to  the  lesion  preserves  the  blood 
supply  to  the  trachea.  The  area  of  stenosis  is 
entered  anteriorly  and  the  segment  is  resected 
until  all  abnormal  tissue  is  removed.  A primary 
anastomosis  of  normal  tracheal  tissue  is  made 
using  4-0  Vicryl  sutures  set  through  the  tracheal 
rings  starting  posteriorly  and  ending  anteriorly 
with  the  patient's  neck  flexed.  It  is  important  to 
keep  the  knots  outside  the  tracheal  lumen  to 
prevent  the  formation  of  granulation  tissue.  The 
thyroid  gland  and  strap  muscles  are  then  closed 
in  the  midline  and  the  skin  is  closed  in  layers 
over  a suction  drain.7 

Recent  animal  models  and  case  reports 
demonstrate  that  blunt  dissection  to  the  carina 
provides  sufficient  mobility  to  allow  for  a 
tension-free  anastomosis  following  resection  of 
2 to  3.5  cm.7  The  maximal  length  of  trachea  that 
can  be  safely  resected  depends  on  factors  such 
as  age,  previous  procedures,  and  patient  morph- 
ology, all  of  which  can  alter  tracheal  mobility  and 
healing.6  In  cases  where  further  measurers  are 
needed  to  decrease  tension,  the  surgeon  has 
several  options.  These  include  placing  tension 
sutures  one  to  two  rings  above  and  below  the 
suture  line,  chin  to  chest  sutures,  and  release 
procedures.  In  the  first  option,  two  lateral 
sutures  placed  through  tracheal  rings  proximal 
and  distal  to  the  line  of  anastomosis  help  to 
relieve  tension  from  the  suture  line.  Chin  to  chest 
sutures  limit  the  patient's  range  of  motion  and 
are  useful  in  patients  at  risk  for  extending  their 
neck,  thereby  disrupting  the  suture  line.  The 
sutures  are  left  for  7 to  10  days  to  ensure 
adequate  healing. 

The  most  commonly  described  muscle 
release  procedures  include  the  infrahyoid  re- 
lease, the  suprahyoid  laryngeal  release,  and  the 
combined  suprahyoid  and  inferior  constrictor 
release.  The  infrahyoid  release  is  performed  by 


278  J La  State  Med  Soc  VOL  152  June  2000 


dividing  the  sternohyoid  and  omohyoid  mus- 
cles, leaving  the  sternothyroid  intact  to  provide 
downward  traction  on  the  laryngotracheal  com- 
plex. The  suprahyoid  release  relieves  tension  by 
transecting  the  hyoid  bone  at  the  lesser  cornu 
and  dividing  the  muscles  from  the  superior 
aspect  of  the  hyoid.  The  combined  procedure  as 
describes  by  Biller8  allows  up  to  6 cm  of  tracheal 
mobility. 

These  procedures  reduce  tension  at  the 
suture  line  by  releasing  the  larynx  from  upward 
forces.  However,  they  also  have  several  compli- 
cations, including  damage  to  the  superior  laryn- 
geal nerves,  aspiration,  and  postoperative  dys- 
phagia secondary  to  the  inability  to  elevate  the 
larynx.  Most  authors  agree  that  such  dysphagia 
is  temporary  as  patients  can  be  taught  to  swallow 
with  therapy.8 

Postoperative  treatment  includes  antibiotics 
for  7 days  and  the  introduction  of  oral  feeding 
between  the  4th  and  7th  postoperative  day.  The 
first  flexible  endoscopic  examination  is  recom- 
mended at  around  the  20th  postoperative  day 
with  a follow-up  endoscopic  examination  done 
at  3 months.  Endoscopic  laser  coagulation  of 
granulation  tissue  can  be  done  at  that  time  if 
necessary.  Long-term  follow-up  is  at  1 and  3 
years.6 

COMPLICATIONS 

Postoperatively,  immediate  concerns  involve  the 
line  of  anastomosis.  The  most  dreaded  complica- 
tions are  dehiscence  of  the  anastomosis  followed 
by  rupture  of  the  innominate  artery.  The  risk  of 
these  complications  is  lessened  by  a meticulous 
closure.  The  most  common  complications  are 
restenosis  and  granulation  tissue  formation  at 
the  anastomotic  site.  Granulation  tissue  forma- 
tion has  been  reduced  by  the  use  of  absorbable 
sutures  and  proper  suture  techniques.  Most 
authors  recommend  extubation  in  the  operating 
room  under  direct  visualization  to  avoid  further 
trauma  to  the  suture  line.25  An  airtight  seal  can 
be  determined  by  withdrawing  the  endotracheal 
tube  to  a position  proximal  to  the  anastomosis 
while  irrigating  and  ventilating.  Other  authors 


recommend  extubation  within  24  to  48  hours  to 
allow  the  anastomotic  site  to  become  airtight.8 
Covering  the  anastomosis  with  a strap  muscle 
flap  further  protects  from  innominate  artery 
rupture. 

The  risk  of  recurrent  nerve  injury  is  reduced 
by  dissecting  close  to  the  trachea.  This  can  be 
somewhat  challenging  around  the  tracheal 
stoma  due  to  scar  formation.  Obstruction  from 
laryngeal  edema  is  minimized  by  the  admin- 
istration of  corticosteroids.  Dysphagia  occurs  as 
a complication  following  release  procedures. 
Experience  has  indicated  that  the  condition  is 
temporary  in  neurologically  intact  patients. 
Finally,  low  tension  at  the  suture  line  significant- 
ly decreases  the  change  of  post-anastomotic 
stricutre.2 


Areas  of  stenosis  formation 
from  tracheostomy  tubes  and 
laryngotracheal  tubes 


Figure.  This  figure  demonstrates  the  most  common 
sites  of  tracheal  stenosis  from  laryngotracheal  and 
tracheostomy  tube  injury. 


J La  State  Med  Soc  VOL  152  June  2000  279 


CONCLUSION 


REFERENCES 


Advances  in  critical  care  medicine  have  led  to 
an  increase  in  survival  for  those  patients  with 
an  otherwise  poor  prognosis.  Many  of  these 
critically  ill  patients  require  prolonged  venti- 
lation, resulting  in  an  increase  in  the  number  of 
cases  of  laryngotracheal  stenosis.  Iatrogenic 
tracheal  stenosis  is  a largely  preventable  and 
curable  problem,  and  the  increased  incidence  of 
post-intubation  tracheal  stenosis  has  lead  to  a 
heightened  awareness  of  risks  from  high- 
pressure  cuffs  and  traction  on  ventilation  tubes. 
Prevention  of  tracheal  injuries  can  be  achieved 
by  maintaining  cuff  pressures  less  than  20  cm 
H20,  using  lightweight  swivel  connectors  be- 
tween the  tracheotomy  tube  and  the  ventilator 
tubing  and  by  stabilizing  the  ventilator  tubing 
to  prevent  traction  of  the  tracheostomy  tube. 
When  the  lesion  is  diagnosed,  surgical  resection 
with  primary  anastomosis  offers  the  best  success 
rate  in  isolated  cases  of  tracheal  stenosis. 


1.  Har-El  G,  Chaudry  R,  Shaha  A,  et  al.  Resection  of 
tracheal  stenosis  with  end-to-end  anastomosis.  Ann 
Otol  Rhinol  Laryngol  1993;102:670-674. 

2.  Grillo  HC,  Mathisen  DJ.  Surgical  management  of 
tracheal  strictures.  Surg  Clin  North  Am  1988;68:511- 
524. 

3.  Grillo  HC.  Management  of  idiopathic  tracheal 
stenosis.  Chest  Surg  Clin  North  Am  1996;6:811-818. 

4.  Bocage  JP,  Caccavale  R,  Lewis  R,  et  al.  Tracheal 
stenosis.  N J Med  1990;87:631-634. 

5.  Grillo  HC,  Donahue  DM.  Postintubation  tracheal 
stenosis.  Chest  Surg  Clin  North  Am  1996;6:725-731. 

6.  Couraud  L,  Jougon  JB,  Velly  JF.  Surgical  treatment 
of  nontumoral  stenosis  of  the  upper  airway.  Ann 
Thorac  Surg  1995;60:250-260. 

7.  Laccourreye  O,  Brasnu  D,  Cauchois  R,  et  al. 
Tracheal  resection  with  end-to-end  anastomosis  for 
isolated  postintubation  cervical  trachea  stenosis: 
long-term  results.  Ann  Otol  Rhinol  Laryngol 
1996;105:944-948. 

8.  Biller  HF,  Munier  MA.  Combined  infrahyoid  and 
inferior  constrictor  muscle  release  for  tension-free 
anastomosis  during  primary  tracheal  repair. 
Otolaryngol  Head  Neck  Surg  1992;107:430-433. 


Dr  Godin  is  Chief  Resident  with  the 
Department  of  Otolaryngology, 
Tulane  University  School  of  Medicine  in 
New  Orleans,  Louisiana. 

Dr  Rodriguez  is  a resident  at 
Tulane  University  School  of  Medicine  in 
New  Orleans,  Louisiana. 

Dr  Hebert  is  Chief  of  ENT  at  the 
Veterans  Administration  Hospital  in 
Biloxi,  Mississippi. 


280  J La  State  Med  Soc  VOL  152  June  2000 





Cerebrovascular  Accident 

Harold  Neitzschman,  MD;  Sanjay  M.  Patel,  MD;  Jessica  Borne,  MD 


A 38-year-old  woman  with  a previous  history  of  cerebrovascular  accident  presented  with  com- 
plex partial  status  epilepticus  and  cortical  blindness.  Elevated  cerebrospinal  fluid  and  blood 
lactic  acid  were  noted.  Family  history  was  pertinent  for  a similar  illness  in  her  deceased  mother. 


Figure  1.  Weighted 
spin  echo  axial  MR 
images. 


Figures  2a  and  2b.  T2-weighted  spin  echo 
axial  and  fast  spin  echo  coronal  MR  images. 


Figures  3a  and  3b.  Gadolinium  enhanced 
What  is  your  diagnosis?  n Spjn  echo  weighted  axial  and  coronal 
Elucidation  is  on  page  282.  image. 


J La  State  Med  Soc  VOL  152  June  2000  281 


Radiology  Case  of  the  Month 
Case  Presentation  is  on  page  281. 

RADIOLOGIC  DIAGNOSIS  - Mitochondrial 
encephalomyopathy 


INTERPRETATION  OF  IMAGING 

Tl-weighted  images  demonstrate  area  of  in- 
creased signal  involving  the  right  occipital  lobe 
(Figure  1).  Abnormal  T2  hyperintensity  is  de- 
monstrated involving  cortical  and  subcortical 
areas  of  the  right  parietal  and  occipital  lobe  in 
a fairly  extensive  distribution.  Note  the  rela- 
tive sparing  of  the  occipital  lobe  medially  (ar- 
rows) (Figures  2a  and  2b).  No  enhancement  on 
corresponding  axial  and  coronal  images  in  the 
right  occipital  lobe  (arrows)  (Figures  3a  and  3b). 

DISCUSSION 

MELAS  syndrone  (mitochondrial  enceph- 
alomyopathy, lactic  acidosis,  and  stroke-like 
episodes)  is  a familial  disease.  A specific  muta- 
tion in  the  mitochondrial  RNA  is  associated 
with  MELAS  syndrome.1  It  is  a group  of  disor- 
ders in  which  stroke  and  stroke-like  episodes, 
nausea,  and  vomiting  accompany  systemic 
signs  of  mitochondrial  dysfunction.  The  neu- 
rological deficits  may  be  permanent  or  revers- 
ible. 

MELAS  syndrome  is  associated  with  el- 
evated serum  and  CSF  lactic  acid  levels.2 
Muscle  biopsy  shows  presence  of  ragged  red 
fibers. 

Imaging  findings  in  MELAS  syndrome 
demonstrate  cerebral  infarcts.  These  abnormali- 
ties may  not  conform  to  vascular  territories. 
Although  any  part  of  the  brain  can  be  affected, 
the  occipital  and  parietal  lobes  are  most  fre- 
quently affected.  The  changes  may  disappear 
and  reappear. 

Magnetc  resonance  spectroscopy  (MRS)  has 
been  used  to  assess  cerebral  metabolism  in 
MELAS  syndrome.3  MRS  shows  an  elevation 


of  the  lactate  peak.  This  finding  has  been  used 
in  screening  patients  suspected  of  having 
MELAS  syndrome. 

REFERENCES 

1.  Gilchrist  fM,  Sikirica  M,  Stopa  E.  Adult  MELAS. 
Evidence  of  involvement  of  neurons  as  well  as 
cerebral  vasculature  in  strokelike  episodes.  Stroke 
1996;27:1420-1423. 

2.  Chung  Hua,  Hsuieh  Tsa  Chih.  Childhood  MELAS 
syndrome  presenting  with  seizure  and  cortical 
blindness:  a case  report.  Chin  Med  J 1998;61:740- 
745. 

3.  Pavlakis  SG,  Kingsley  PB,  Kaplan  GP.  Magnetic 
resonance  spectroscopy:  use  in  monitoring  MELAS 
treatment.  Arch  Neurol  1998;55:849-852. 


Dr  Neitzschman  is  Associate  Professor  of 
Radiology  and  Nuclear  Medicine  at 
Louisiana  State  University  Health  Sciences  Center 
in  New  Orleans,  Louisiana. 

Dr  Patel  is  a senior  resident  at 
Louisiana  State  University  Health  Sciences  Center 
in  New  Orleans,  Louisiana. 

Dr  Borne  is  Assistant  Professor  of  Clinical  Radiology  at 
Louisiana  State  University  Health  Sciences  Center 
in  New  Orleans,  Louisiana. 


282  J La  State  Med  Soc  VOL  152  June  2000 


The  Journal  150  t 


June  1850  and  1900 


Gustavo  A.  Colon,  MD 


In  June  1850,  the  report  of  New  Orleans 
Charity  Hospital  was  submitted  to  the  Jour- 
nal. The  report  is  as  follows:  "This  hospital 
with  its  accessory  buildings  occupies  one  entire 
square,  three  sides  of  which  are  covered  with 
magnificent  three  and  four  story  buildings.  The 
main  building  fronts  on  Common  Street  and  the 
two  lateral  wings  extending  in  the  rear  to  the 
depth  of  the  square  are  used  one  for  the  accom- 
modation of  female  patients  and  the  other  as  a 
refractory,  laundry  rooms,  and  the  accommoda- 
tions of  Sisters  of  Charity.  The  space  between 
these  two  wings  and  in  the  rear  of  the  main 
building  is  planted  with  shrubbery  and  inter- 
sected at  intervals  with  elegant  walks  covered 
with  shells  and  pebbles.  Across  this  vacant 
square  runs  a rail  track  from  one  wing  to  the 
other  which  serves  to  convey  the  furniture, 
goods,  provisions,  etc.  from  one  wing  to  the 
other.  The  hospital  buildings  can  easily  accom- 
modate about  1200  patients,  the  females  being 
separated  from  the  male  wards,  arrangements 
called  for  by  every  consideration  of  decent  pro- 
priety and  the  usages  of  civilized  society.  No  en- 
demic or  contagious  diseases  is  at  present  preva- 
lent in  the  City  or  in  the  Hospital;  indeed  the 
health  of  the  institution  is  most  satisfactory  and 


the  daily  admissions  continue  to  rise." 

There  is  an  editorial  comment  on  an  article 
by  Dr  Professor  Berthold  who  the  editor  states 
made  some  interesting  experiments  on  Trans- 
plantation of  Testicles  and  includes  the  following 
principles: 

1 . That  testicles  may  be  transplanted  and 
will  unite  with  living  structures  after 
the  removal  from  the  body.  Not  only 
when  placed  in  their  ordinary  situa- 
tion but  even  in  an  abnormal  locality. 

2.  That  the  organ  in  this  situation,  exactly 
like  a grafted  branch,  retains  specific 
properties  and  secretes  its  natural  flu- 
ids. 

3.  That  the  specificity  of  nerves  is  not  in- 
dispensable to  the  preservation  of 
functions. 

4.  That  separation  of  testicles  does  not 
deprive  the  individual  of  the  charac- 
ter of  its  species  when  care  is  taken  to 
preserve  this  organ  in  another  part  of 
the  body;  so  that  it  would  seem  that 
the  action  of  the  fluids  secreted  in  the 
testicles  suffices,  by  its  contact  with  the 
blood,  to  give  the  definitive  character 
particular  to  the  species. 

J La  State  Med  Soc  VOL  152  June  2000  283 


it 
2 ! 

c i r 


(!) 
Il  J 
I,  ) 


There  is  an  article  in  the  New  Orleans  Medical 
and  Surgical  Journal  of  1900  which  talks  about 
the  recent  history  of  Small  Pox  in  New  Orleans. 
Obviously,  Small  Pox  was  a very  feared  disease 
because  of  its  infectious  nature  and  all  cases, 
once  they  were  discovered,  were  put  under 
prompt  isolation  and  the  premises  and  even 
neighborhoods  would  be  put  under  quarantine 
in  order  to  prevent  spread  of  the  disease.  How- 
ever, there  was  an  unfortunate  development  that 
occurred  when  there  was  an  infection  at  Char- 
ity Hospital,  which  did  not  usually  admit  Small 
Pox  patients.  But  a patient  was  admitted  who 
did  not  develop  the  Small  Pox  pustules  imme- 
diately after  admission  and  subsequently  in- 
fected some  of  the  patients  on  the  other  wards. 

Of  the  232  cases  that  occurred  in  New  Or- 
leans in  the  year  1899,  of  which  there  were  only 
five  deaths,  all  received  treatment  at  the  Small 
Pox  Hospital,  which  was  a separate  hospital  for 
Small  Pox  patients.  The  regulations  of  the  Health 
Department  in  New  Orleans  for  Small  Pox  were 
as  follows:  Upon  the  discovery  of  the  case,  the 
patient,  if  unable  to  procure  necessary  attention 
immediately  either  at  the  home  or  elsewhere, 
was  removed  to  the  Small  Pox  Hospital  in  an 
ambulance  or  a vehicle  which  had  been  disin- 
fected with  the  liberal  use  of  bichloride  of  mer- 
cury and  water.  The  room  from  which  the  pa- 
tient had  been  removed  was  also  disinfected.  If 
the  patient  was  able  to  procure  proper  attention 
at  home,  the  house  would  be  quarantined  ac- 
cording to  the  reliability  of  the  family  and  other 
inmates  in  the  house  and  according  to  the  abil- 
ity of  Board  of  Health  to  pay  for  the  service.  The 
house  would  be  guarded  day  and  night  and 
vaccination  would  be  urged  to  all  who  would 
submit  to  it  within  the  household,  but  they 
would  be  quarantined  in  the  house  and  not  al- 
lowed to  leave. 

The  house  or  a portion  of  the  house  which 
was  infected  would  have  a plaque  guard  placed 
on  it  so  that  anyone  entering  that  area  would 
know  that  it  was  a house  with  Small  Pox.  Bichlo- 
ride solution  would  be  furnished  by  the  Health 
Department  with  instructions  for  its  use  and 
strict  isolation  would  be  enjoined  and  enforced 


according  to  the  number  of  people  affected 
within  the  household.  In  case  of  death,  sanitary 
inspectors  would  be  immediately  dispatched  to 
the  house;  the  body  would  be  thoroughly  satu- 
rated with  a bichloride  solution,  wrapped  in  a 
sheet  soaked  in  same  as  soon  as  possible,  and 
placed  in  a coffin  saturated  with  the  solution  and 
immediately  closed  and  sealed.  The  funeral 
would  take  place  as  soon  as  possible,  always  on 
the  day  of  death.  The  funeral  would  be  private 
and  the  coffin  would  be  handled  entirely  by  sani- 
tary inspectors  who  would  also  disinfect  the 
hearse  and  carriage.  The  room  or  rooms  in  the 
house  infected,  after  being  sealed  by  pasting 
paper  strips  over  all  the  cracks,  openings,  and 
frames,  would  be  subjected  to  fumes  of  sulfur 
for  about  14  hours  for  appropriate  fumigation. 
The  floor,  walls,  and  wood  work,  as  well  as  any 
other  portion  of  the  house  which  was  felt  to  be 
infected,  would  be  washed  with  bichloride  so- 
lution. The  bed  clothes,  the  mattresses,  and  all 
textile  fabrics  which  came  in  contact  with  the 
infected  patient  would  be  destroyed  by  fire  or 
submitted  to  boiling  for  an  hour  or  more,  or 
soaked  in  a bichloride  solution.  But  sometimes 
the  addition  of  sulfur  fumes  were  applied  to  the 
contents  of  a room.  The  same  methods  of  disin- 
fection would  also  be  done  in  the  premises  of  a 
patient  who  recovered.  The  question  was  when 
should  the  sanitary  discharge  of  a convalescent 
patient  take  place  and  the  period  of  detention 
cease.  It  was  the  experience  of  the  Health  De- 
partment that  time  cannot  properly  indicate  a 
period  of  quarantine  in  all  cases,  but  it  was  felt 
that  3 weeks  might  be  considered  the  average 
duration  of  infection  and,  although  many  cases 
could  be  free  of  contamination  prior  to  that,  it 
was  felt  that  this  period  was  appropriate  for 
quarantine  and  detention.  This  circular  was 
passed  to  all  physicians  in  the  New  Orleans  area 
by  the  Health  Department: 


Dear  Doctor:  The  interval  of  time  between 
the  clinical  recovery  and  the  termination  of 
the  period  of  infection  in  variola  usually  be- 
ing quite  long , the  attending  physician  is  re- 
quested to  advise  this  office  of  the  recovery  of 


284  J La  State  Med  Soc  VOL  152  June  2000 


his  patient  whereupon  the  Board  of  Health 
will  assume  sanitary  charge  of  the  case  and 
determine  through  its  officer  the  date  of  dis- 
infection subject  always  to  the  cooperation 
and  advise  of  the  medical  attendant.  -Signed 
the  New  Orleans  Health  Department. 


It  was  felt  by  most  physicians  at  that  time  that 
the  patient  was  not  infective  after  the  last  scab 
had  fallen  off  and  the  skin  was  free  of  any  in- 
fected particles  or  drainage  that  may  be  coming 
from  the  pustules  or  until  the  last  brown  spot 
and  dried  pustule  had  disappeared.  It  was  pre- 
sumed by  physicians  at  that  time  that  an  uni- 
dentified germ  was  the  cause  of  variola,  that  the 
majority  of  Small  Pox  cases  were  among  the 
lesser-informed  and  poorer  population,  that 
Small  Pox  among  the  well-to-do  and  intelligent 
did  not  spread  nor  gain  a foothold  because  the 
community  was  willing  to  pay  for  the  cost  of 
prevention  however  expensive,  and  that  one 
must  measure  the  economy  of  a City  by  preven- 
tion and  quarantine,  if  necessary. 


Dr  Colon  has  a plastic  surgery  practice  in 
Metairie,  Louisiana  and  has  lectured  on  history  of  medicine 
at  Louisiana  State  University  Health  Services  Center  and 
Tulane  University  School  of  Medicine, 
both  in  New  Orleans,  Louisiana. 

Editor's  Note:  The  author  and  the  Journal  welcome  comments 
on  the  history  of  medicine. 


Can  We  Prevent  Type  1 Diabetes? 

Stuart  A.  Chalew,  MD 


Preliminary  laboratory  and  clinical  studies  suggest  that  the  clinical  onset  of  type  1 diabetes 
can  be  delayed  or  prevented  in  high-risk  individuals.  The  NIH  sponsored  Diabetes  Prevention 
Trial  Type  1 is  currently  underway  to  determine  whether  prevention  is  possible  using  insulin 
to  alter  the  autoimmune  process. 


Type  1 diabetes  occurs  due  to  the  autoim- 
mune destruction  of  the  insulin  secret- 
ing beta  cells  of  the  pancreatic  islets.  By 
the  time  most  patients  become  clinically  hyper- 
glycemic they  have  irrevocably  lost  80%  to  90% 
of  their  beta  cells.1  They  are  now  dependent  on 
exogenous  insulin  injections  for  survival. 

It  is  estimated  that  over  1 million  individu- 
als in  the  United  States  have  type  1 diabetes  and 
another  50,000  develop  diabetes  each  year.1  Prior 
to  the  1920s,  a diagnosis  of  autoimmune  type  1 
diabetes  (also  referred  to  as  "juvenile  onset  dia- 
betes" or  "insulin  dependent  diabetes")  was 
tantamount  to  a death  sentence.  It  wasn't  a mat- 
ter of  if  you  would  imminently  die,  it  was  only 
a question  of  how  soon.  The  discovery  and  de- 
velopment of  insulin  for  clinical  use  by  Banting, 


Best,  Collip,  and  Macleod  in  1922  changed  the 
treatment  and  prognosis  of  type  1 diabetes  for- 
ever. However,  injected  insulin  is  not  a cure  for 
diabetes.  And  although  most  new  cases  of  type 
1 diabetes  do  not  succumb  to  acute  metabolic 
derangements,  patients  are  prone  to  develop- 
ing severe  complications  such  as  nephropathy, 
retinopathy,  and  neuropathy  over  the  years. 
Currently  treatment  of  diabetes  and  palliative 
therapy  of  diabetes  complications  costs  billions 
of  dollars  per  year  in  the  United  States. 

Type  1 diabetes  occurs  in  individuals  with  a 
combination  of  genetic  susceptibility  and  envi- 
ronment exposures.2  However,  the  precise 
causes  of  type  1 diabetes  are  unclear.  Despite 
the  lack  of  definitive  understanding  of  its  patho- 
genesis, techniques  have  been  developed  which 


286  J La  State  Med  Soc  VOL  152  June  2000 


allow  the  identification  of  individuals  at  high 
risk  of  developing  autoimmune  diabetes.2,3  First 
degree  relatives  of  individuals  who  already  have 
type  1 diabetes  are  themselves  at  higher  risk  than 
the  general  population.  In  addition  the  presence 
of  circulating  antibodies  directed  against  beta 
cell  constituents  further  increases  the  likelihood 
that  diabetes  will  develop.2  As  autoimmune 
damage  to  the  pancreas  progresses,  insulin  se- 
cretion in  response  to  intravenous  glucose  be- 
comes impaired.  The  combination  of  antipan- 
creatic  antibodies  and  impaired  response  to  the 
intravenous  glucose  tolerance  test  is  predictive 
of  those  who  are  at  high  risk  for  progression  to 
clinical  diabetes. 

Once  destroyed,  beta  cell  function  cannot  be 
recovered,  and  the  individual  with  clinical  dia- 
betes faces  lifelong  therapy  with  insulin  injec- 
tions and  the  potential  burden  of  complications. 
The  high  costs  in  human  suffering  and  health 
care  resources  associated  with  diabetes  has 
stimulated  great  interest  in  prevention  of  au- 
toimmune diabetes  before  beta  cell  destruction 
is  complete.  Several  interventions  have  been 
considered  for  the  protection  of  high-risk  indi- 
viduals. Research  conducted  in  animal  models 
of  diabetes  has  suggested  that  preclinical  au- 
toimmune diabetes  can  be  prevented  or  delayed 
by  the  use  of  insulin.3  Small  scale  studies  of  in- 
sulin in  humans  have  also  suggested  that  this 
approach  may  prove  effective.  The  encouraging 
results  of  preliminary  animal  and  human  stud- 
ies prompted  the  organization  of  a nationwide 
clinical  intervention  trial  in  the  United  States 
organized  by  the  NIH.  The  project  was  entitled 
the  Diabetes  Prevention  Trial  Type  1 or  DPT-1. 

The  goals  of  the  DPT-1  are  to  identify  indi- 
viduals who  are  at  high  risk  for  development  of 
autoimmune  diabetes  and  offer  them  the  oppor- 
tunity to  participate  in  the  investigational  trial 
with  either  oral  or  parental  insulin.  First  degree 
relatives  (children,  siblings,  parents)  of  patients 
with  type  1 diabetes  age  3-45  years  of  age  and 
second  degree  relatives  (cousins,  aunts,  uncles, 
nieces,  nephews,  grandchildren)  between  the 
ages  of  3-20  years  are  screened  for  the  presence 
of  islet  cell  autoantibodies.  Individuals  who  are 


positive  for  islet  cell  antibodies  are  then  further 
staged  for  risk  of  developing  diabetes  by  intra- 
venous glucose  tolerance  test.  Individuals  found 
to  have  a 25%  to  50%  chance  of  developing  type 
1 diabetes  in  the  next  5 years4  are  offered  par- 
ticipation in  the  oral  insulin  arm  of  the  study. 
Participants  in  this  part  of  the  study  are  random- 
ized to  receive  capsules  containing  insulin  or 
placebo.  The  study  seeks  to  recruit  490  partici- 
pants into  this  section  of  the  study.  Although 
insulin  taken  orally  does  not  enter  the  blood 
stream,  it  is  hypothesized  that  interaction  with 
the  immune  system  on  the  GI  tract  will  alter  the 
autoimmune  attack  on  the  pancreatic  islets. 

High  risk  subjects,  those  individuals  with 
greater  than  50%  chance  of  developing  diabe- 
tes4 in  the  coming  5 years,  are  randomized  to 
receive  therapy  with  parenteral  insulin  or  are 
closely  monitored  for  development  of  diabetes. 
It  was  not  deemed  ethical  to  randomize  subjects 
to  receive  parenteral  placebo  injections.  The 
study  seeks  to  recruit  340  subjects  to  this  part  of 
the  study. 

Although  the  hypothesis  of  the  study  is  that 
insulin  therapy  will  modulate  the  immune 
mechanism  in  a way  that  will  either  prevent  or 
delay  the  onset  of  clinical  diabetes,  it  is  possible 
that  exposure  to  insulin  could  accelerate  the 
clinical  onset  of  diabetes.  The  study  will  have 
the  power  to  detect  the  possibility  that  oral  or 
parenteral  insulin  exposure  exacerbates  the  im- 
mune destruction  of  pancreatic  beta  cells. 

Participants  benefit  from  the  study  in  sev- 
eral ways.  Individuals  screened  through  the 
DPT-1  learn  their  personal  risk  of  developing 
diabetes.  Individuals  at  intermediate  and  high 
risk  of  developing  diabetes  will  be  closely  moni- 
tored during  the  study  and  the  onset  of  clinical 
diabetes  would  be  detected  at  a very  early  stage. 
If  the  experimental  hypothesis  is  correct,  those 
receiving  the  intervention  would  have  a delay 
or  interruption  in  their  progression  to  clinical 
diabetes. 

In  order  to  promote  awareness  of  the  DPT-1 
study  and  facilitate  screening  of  eligible  indi- 
viduals, Regional  Recruiting  Centers  were  or- 
ganized around  the  country  in  1998.  The  Re- 


J La  State  Med  Soc  VOL  152  June  2000  287 


gional  Recruiting  Center  for  the  Gulf  Region  is 
in  New  Orleans  and  has  been  helping  health  care 
professionals  screen  the  families  of  their  patients 
who  have  type  1 diabetes.  The  Gulf  Regional 
Center  has  helped  organize  group  screenings  in 
Louisiana,  Mississippi,  and  Alabama.  These 
screenings  have  been  at  doctors'  offices,  hospi- 
tals, diabetes  camps,  health  fairs,  family  re- 
unions, and  diabetes  awareness  programs.  Kits 
are  available  to  allow  the  convenience  of  screen- 
ing individuals  in  the  office  of  their  physicians. 
The  DPT-1  reimburses  physicians  for  such  of- 
fice screening.  Physicians,  health  care  providers, 
and  others  who  wish  to  be  screened  or  would 
like  to  set  up  a screening  program  for  their  com- 
munity can  contact  the  New  Orleans  Center  at 
(504)894-5139  for  further  information.  The  na- 
tional study  information  phone  number  is 
(800)425-8361.  Participation  in  the  study  at  all 
stages  is  free  of  charge. 

Thus,  within  the  next  decade,  the  DPT-1  will 
provide  important  information  which  we  will 
use  to  prevent  Type  1 diabetes. 

REFERENCES 

1.  Kukreja  A,  Maclaren  NK.  Autoimmunity  and 
diabetes.  J Clin  Endocrinol  Metab  1999;84:4371-4378. 

2.  Gottlieb  PA,  Eisenbarth  GS.  Diagnosis  and 
treatment  of  pre-insulin  dependent  diabetes.  Annu 
Rev  Med  1998;49:391-405. 

3.  Rabinovitch  A,  Skyler  JS.  Prevention  of  type  1 
diabetes.  Med  Clin  North  Am  1198;82:739-755. 

4.  Krischer  JP,  Schatz  K,  Riley  WJ.  Insulin  and  islet 
cell  autoantibodies  as  time-dependent  covariates 
in  the  development  of  insulin-dependent  diabetes: 
a prospective  study  in  relatives.  J Clin  Endocrinol 
Metabol  1993;77:743-749. 


Dr  Chalew  is  Professor  of  Pediatrics  and 
Director  of  Pediatric  Endocrinology  at  the 
Eouisiana  State  University  Health  Sciences  Center 
and  at  Children's  Hospital , both  in 
New  Orleans , Eouisiana. 


288  J La  State  Med  Soc  VOL  152  June  2000 


Pathologic  Disruption  of  the  Distal  Biceps 
Brachii  Tendon  by  Synovial  Sarcoma 

Michael  T.  Duplechain,  BS;  Morgan  P.  Lorio,  MD; 
and  Richard  G.  Lastrapes,  MD 


This  article  illustrates  the  utility  of  musculoskeletal  magnetic  resonance  imaging  in  providing 
contrast  resolution  of  soft  body  tissues  (ie,  biceps  tendon)  and  pathologic  processes  (ie,  synovial 
sarcoma).  The  evaluation  of  biceps  tendon  injury  and  the  diagnosis/staging  of  synovial  sarcoma 
are  best  complemented  by  this  most  sensitive,  non-invasive  imaging  method,  particularly 
when  combined  as  in  this  unique  case. 


A 40-year-old  right-hand  dominant  man 
presented  with  an  expanding  antecu- 
bital  mass  and  acute  pain  extending  into 
his  left  forearm  as  well  as  weak  external  rota- 
tion of  the  left  upper  extremity,  a result  of  a 
work-related  injury.  A distinct  and  audible  tear 
was  felt  at  the  time  of  the  injury.  His  shoulder 
was  pain-free.  The  patient  was  neurovascularly 
intact.  Past  history  and  review  of  symptoms 
were  negative.  Plain  radiographs  of  the  patient's 
left  arm  were  normal.  Magnetic  resonance  im- 
ages of  the  patient's  left  arm  were  acquired  (see 
Figures  la-ld  on  following  page).  Pathology  re- 
ports revealed  the  biopsied  mass  to  be  synovial 
sarcoma,  biphasic  type.  Intra-operative  gross 
surgical  findings  confirmed  both  hemorrhage 


and  necrosis.  The  traumatic  rupture  of  our 
patient's  tumor /tendon  precluded  limb  salvage 
surgery.  The  neurovascular  involvement  by  the 
tumor  rupture  secondary  to  hematoma  contami- 
nated the  surrounding  muscle  compartments. 
Potential  local  and  metastatic  involvement  have 
been  treated  with  brachytherapy  and  chemo- 
therapy, respectively. 

DIAGNOSIS:  Partial  pathologic  disruption  of  the 
hrachii  biceps  tendon  by  synovial  sarcoma. 

DISCUSSION 

Rupture  of  the  distal  biceps  brachii  tendon  has 
been  historically  rare,  though,  for  reasons  that 


J La  State  Med  Soc  VOL  152  June  2000  289 


are  unclear,  the  incidence  of  this  injury  has  in- 
creased in  recent  years.12  The  disruption  is  most 
common  in  the  dominant  arm  of  middle-aged 
men  (average  age  55)  who  are  involved  in  heavy 
labor  or  activity  (lifting,  pulling,  or  catching 
heavy  objects  or  participating  in  sports).1'3  A 
forceful  eccentric  contraction  of  the  the  biceps 
against  resistance  which  exceeds  the  strength  of 
the  tendon's  distal  attachment  is  the  proposed 


Figure  la.  Sagittal  T1 -weighted  (repetition  time  msec/ 
echo  time  = 600/14)  MR  image  shows  the  large  mass 
projecting  into  the  region  of  the  biceps  brachii  muscle 
with  loss  of  the  normal  signal  within  the  distal  biceps 
tendon  proximal  to  the  insertion  into  the  radial  tuberosity. 


Figure  1c.  FSE  sagittal  T2-weighted  (3850/90)  MR 
image  demonstrates  multi-focal  areas  of  increased 
signal  within  the  lesion  with  thickening  and  abnormal 
signal  within  the  distal  biceps  tendon. 


avulsion  mechanism.4  Complete  disruption  of 
the  tendon  from  its  insertion  onto  the  radial  tu- 
berosity is  most  commonly  observed.1  Partial 
tears  are  thought  to  be  less  common.13  Factors 
such  as  deficient  vascular  supply  and  impinge- 
ment may  contribute  to  the  injury.3  This  report 
discusses  a unique  case  involving  pathologic 
disruption  of  the  biceps  brachii  tendon  by  syn- 
ovial sarcoma. 


Figure  1b.  Axial  T1 -weighted  (600/14)  MR  image 
confirms  the  large  mass  within  the  region  of  the  biceps 
brachii  muscle  with  signal  greater  than  that  of  adjacent 
muscle. 


Figure  Id.  FSE  axial  T2-weighted  (3850/85)  MR  image 
shows  the  fluid  level  within  this  lesion. 


290  J La  State  Med  Soc  VOL  152  June  2000 


MR  images  can  be  used  in  the  evaluation  of 
biceps  tendon  injuries  and  thereby  assist  in  sur- 
gical planning.  Sagittal  images  are  particularly 
useful  for  detecting  tear  levels,  locating  tendon 
ends,  and  reporting  the  size  of  the  resulting  de- 
fect. For  confirming  complete  versus  partial 
tears,  evaluating  the  extent  of  the  tendon  diam- 
eter involved  in  partial  tears,  and  evaluating 
surrounding  hemorrhage  or  bursitis,  axial  im- 
ages are  invaluable.3  T2- weighted  axial  images 
are  most  beneficial  in  determining  the  degree  of 
tendon  tear.1 

Synovial  sarcoma,  representing  8%  to  10%  of 
all  soft-tissue  sarcomas,  is  a malignant  soft  tis- 
sue neoplasm  commonly  arising  near,  but  not 
necessarily  from,  the  synovium  of  joint  capsules, 
bursae,  or  tendon  sheaths.56  Actually,  true  in- 
tra-articular  synovial  sarcomas  are  decidedly 
rare.7  Multipotential  mesenchymal  cells  have 
been  identified  as  the  likely  source  of  these  sar- 
comas.68 Typically,  patients  with  synovial  sar- 
coma are  young  adults  between  the  ages  of  15 
and  35.8  There  is  also  a slight  male  predominance 
(ratio  between  2:1  and  3:2).6'9  Patients  present 
with  a mass  or  pain  or  both.89 

Two  histological  forms  of  synovial  sarcoma 
exist.  The  classic,  or  biphasic  form,  is  character- 
ized by  a background  stroma  consisting  of 
densely  packed  fibroblast-like  cells  among  which 
epithelial-like  cells,  usually  arranged  in  glandu- 
lar formations,  are  scattered.6  The  monophasic 
form  is  described  by  a malignant  spindle-cell 
population  with  no  gland-forming  compo- 
nents.67 Rarely,  the  monophasic  form  manifests 
exclusively  epithelial  features.6  Additional  his- 
topathologic features  of  synovial  sarcoma  in- 
clude calcifications,  intraluminal  secretions, 
myxoid  changes,  and  varying  degrees  of  collagen 
deposition.  Such  features  are  not  specific  to  syn- 
ovial sarcoma  but  are  part  of  its  morphologic 
spectrum  and  therefore  may  contribute  to  diag- 
nosis.10 Synovial  sarcomas  have  the  propensity 
to  metastasize  to  the  lung,  lymph  nodes,  and 
bone  marrow.  Metastatic  lesions,  in  most  series, 
develop  in  more  than  50%  to  70%  of  patients.6 

MR  images  are  useful  for  staging  synovial 
sarcoma  involvement.  The  characteristic  feature 


on  these  images  is  a heterogenous,  multilocular 
mass  with  internal  septation.  Multiple  fluid- 
filled  levels  (secondary  to  hemorrhage)  with  ex- 
tensive loculations  have  also  been  reported. 
Lesions  are  of  low  to  intermediate  signal  inten- 
sity on  Tl-weighted  images  and  demonstrate 
bright  homogeneity  on  T2-weighted  images. 
Higher  signal  intensity  delineates  areas  of  cen- 
tral necrosis.8  In  our  patient,  surgical  findings 
which  verified  hemmorhage  and  necrosis  cor- 
related well  with  T-2  weighted  images,  estab- 
lishing the  efficacy  of  these  images. 

REFERENCES 

1.  Fritz  RC,  Stoller  DW.  The  elbow.  In:  Stoller 
DW.  Magnetic  Resonance  Imaging  in  Ortho- 
paedics and  Sports  Medicine  2nd  edition. 
Philadelphia:  Lippincott-Raven;  1997:  743- 
849. 

2.  Morrey  BF.  Distal  biceps  tendon  rupture.  In: 
Morrey  BF  (editor).  Master  techniques  in  or- 
thopaedic surgery:  the  elbow.  New  York:  Raven 
Press;  1994:115-128. 

3.  Ho  CP.  MR  imaging  of  tendon  injuries  in  the 
elbow.  MRI  Clin  North  Am , 1997;  5:  529-543. 

4.  Davison  BL,  Engber  WD,  Tigert  LJ.  Long 
term  evaluation  of  repaired  distal  biceps 
brachii  tendon  ruptures.  Clin  Orthop  Related 
Res  1996;333:186-191. 

5.  Sanchez  RJM,  Alcaraz  MM,  Quinones  TD, 
et  al.  Extensively  calcified  synovial  sarcoma. 
Skel  Radiol  1997;26:671-673. 

6.  Soliman  AM,  Shikani  AH.  Pathologic  quiz 
case  2.  Synovial  sarcoma  of  the  hypophar- 
ynx.  Arch  Otolaryngol  Head  Neck  Surg  1995; 
121:1059,1061-1062. 

7.  Bullough  PG.  Atlas  of  Orthopedic  Pathology 
with  Clinical  and  Radiologic  Correlations  2nd 
edition.  New  York:  Gower  Medical  Publish- 
ing; 1992:17.22-17.24. 

8.  Stoller  DW,  Johnston  JO,  Steinkirchner  TM. 
Bone  and  soft-tissue  tumors.  In:  Stoller  DW. 
Magnetic  Resonance  Imaging  in  Orthopaedics 
and  Sports  Medicine  2nd  edition.  Philadel- 
phia: Lippincott-Raven;  1997:1231-1237. 

9.  Carnesale  PG.  Soft  tissue  tumors  and  non- 


J La  State  Med  Soc  VOL  152  June  2000  291 


neoplastic  conditions  simulating  bone  tu- 
mors. In:  Crenshaw  AH  (editor).  Campbell's 
Operative  Orthopaedics  8th  edition.  St  Louis: 
Mosby  - Year  Book;  1992;1:291-314. 

10.  Ryan  MR,  Stastny  JF,  Wakely  PE.  The  cyto- 
pathology  of  synovial  sarcoma:  a study  of  six 
cases,  with  emphasis  on  architecture  and  his- 
topathologic correlation.  Cancer  1998;84:42- 
49. 

11.  Singer  S,  Baldini  EH,  Demetri  GD,  et  al.  Syn- 
ovial sarcoma:  prognostic  significance  of  tu- 
mor size,  margin  of  resection,  and  mitotic 
activity  for  survival.  J Clin  Oncol  1996;14: 
1201-1208. 


Mr  Duplechain  is  a second-year  medical  student  at 
Louisiana  State  University  School  of  Medicine, 
New  Orleans,  Louisiana. 

Dr  Lorio  is  an  orthopaedic  hand  surgeon.  His  private 
practice,  Orthopaedic  Surgical  Associates  of  Acadiana,  is 

located  in  Opelousas,  Louisiana. 

Dr  Lastrapes  is  a diagnostic  radiologist.  His  private 
practice,  St  Landry  Radiology  Associates,  is  located  in 

Opelousas,  Louisiana. 


292  J La  State  Med  Soc  VOL  152  June  2000 


Hypertension  Treatment  in  the  New  Millennium: 
The  Importance  of  Controlling 
Systolic  Blood  Pressure  and 
the  Pulse  Pressure 

F.  Gilbert  McMahon,  MD  and  Edward  Frohlich,  MD 


The  sixth  Joint  National  Committee  on  Hypertension  (JNC-VI)  has  recently  been  published. 
The  new  criteria  emphasize  the  importance  of  controlling  systolic  blood  pressure  and  paying 
attention  to  the  level  of  pulse  pressure.  The  authors  believe  in  the  importance  of  controlling 
both  in  compliance  with  the  new  criteria  established  by  JNC-VI. 


We  suspect  that  the  vast  majority  of 
physicians  practicing  today  were 
taught  to  diagnose  hypertension 
when  blood  pressure  exceeded  140  / 90  mm  Hg. 
In  addition,  emphasis  was  placed  on  the  diag- 
nosis and  treatment  of  the  diastolic  pressure. 
This  is  no  longer  true.  Evidence  has  accumulated 
that  the  systolic  pressure  is  the  more  important 
factor.  Systolic  hypertension  is  clearly  associated 
with  an  increase  in  morbidity  and  mortality,  its 
presence  needs  to  be  recognized,  and  its  man- 
agement is  imperative.  In  addition,  pulse  pres- 
sure has  emerged  as  a clinically  important  risk 
factor  in  cardiovascular  disease.  Although  dias- 
tolic pressure  increases  with  age  until  about  60 
years  in  industrialized  societies,  increase  is  more 
often  found  in  middle  adulthood.  Diastolic  pres- 


sure generally  plateaus  after  60  years  of  age,  un- 
like systolic  pressure  that  continues  to  increase 
with  age.  Formerly  we  defined  systolic  hyper- 
tension as  >160  mm  Hg,  with  a diastolic  of  90 
mm  Hg  or  less.  As  people  age,  the  arterial  walls 
stiffen  and  become  less  compliant.  Hypertension 
is  much  more  frequent  in  the  elderly.  Upon  closer 
observation,  it  is  often  due  to  systolic  elevations. 
As  a result  of  this,  morbidity  and  mortality  are 
increased. 

The  landmark  study.  Systolic  Hypertension 
in  the  Elderly  (SHEP),  was  published  in  1991.1 
In  it,  2,365  patients  over  age  60  were  followed 
for  5 years.  Baseline  systolic  pressure  was  >160 
mm  Hg  and  diastolic  pressures  were  <90  mm 
Hg.  Patients  received  a low  dose  of  a diuretic  (a 
beta-blocker  was  added  if  necessary).  Patients 


J La  State  Med  Soc  VOL  152  June  2000  293 


were  given  either  this  active  regimen  or  an  iden- 
tical placebo.  After  5 years,  deaths  from  coro- 
nary heart  disease  were  20%  less  among  those 
on  active  treatment  compared  with  the  placebo 
group  and  strokes  were  36%  less  as  well. 

The  sixth  report  of  the  Joint  National  Com- 
mittee on  Prevention,  Detection,  Evaluation,  and 
Treatment  of  High  Blood  Pressure  (JNC-VI)  was 
recently  published.2  The  Table  below  lists  the 
new  definition  of  normal  blood  pressure,  high 
normal,  and  Stages  1,  2,  and  3 of  hypertension. 


Table 

JNC-VI  definition  of  hypertension.2 

Stage 

Value 

Normal 

<130/<85mmHg 

High  Normal 

130-139/85-89  mm  Hg 

Stage  1 Hypertension 

140-159/90-99  mm  Hg 

Stage  2 Hypertension 

160-179/100-109  mm  Hg 

Stage  3 Hypertension 

>1 80/>1 1 0 mm  Hg 

Clinicians  seem  to  be  unaware  that  normal 
blood  pressure  is  <130/  <85  mm  Hg.  Even  high 
normal  blood  pressures  ideally  need  to  be  ap- 
preciated and  managed.  Frequently  two  or  even 
three  drugs  may  be  necessary  to  reduce  a 
patient's  blood  pressure  into  an  acceptable  range 
- preferably  <130/  <85  mm  Hg.  The  JNC-VI  now 
defines  a systolic  blood  pressure  of  140  or  higher 
on  at  least  three  separate  occasions  as  being  hy- 
pertensive.2 A recent  Framingham  report  indi- 
cates that  among  patients  aged  60  or  older,  46% 
had  both  systolic  and  diastolic  elevations,  53% 
had  systolic  hypertension  alone,  whereas  only 
1%  had  diastolic  hypertension  alone.3 

THE  IMPORTANCE  OF  PULSE  PRESSURE 

Pulse  pressure  is  the  arithmetic  difference  be- 
tween the  systolic  and  diastolic  blood  pressures. 


It  represents  primarily  the  pressure  exerted  on 
the  arterial  wall  by  the  surge  of  blood  from  the 
heart  during  systole.  Because  arteries  in  elderly 
patients  are  less  distensible,  a high  pulse  pres- 
sure is  frequently  recognized.  Pulse  pressure  is 
usually  £45  mm  Hg;  Stages  1,  2,  and  3 usually 
have  pulse  pressures  of  50-60  mm  Hg  or  more. 
These  pulse  pressures  reflect  predominately  the 
rising  systolic  pressure.  The  important  message 
is  that  too  few  patients  with  hypertension  are 
actually  receiving  adequate  treatment.  It  is  criti- 
cally important  for  all  physicians  to  measure 
blood  pressure  accurately,  and,  if  the  pressure  is 
elevated  on  three  occasions,  initiate  therapy  with 
a diuretic,  beta-adrenergic  receptor  blocker,  or  a 
dihydropyridine  calcium  antagonist.  If  pressure 
remains  elevated,  additional  antihypertensive 
medication  is  indicated.  A patient  with  180/ 110 
mm  Hg  pressure  is  now  graded  as  Stage  3 hy- 
pertension, with  both  systolic  and  diastolic  pres- 
sures elevated.  Initial  treatment  may  change 
such  a patient's  pressure  to  185/90  mm  Hg, 
graded  as  Stage  3 isolated  hypertension.  How- 
ever, such  treatment  would  actually  increase  the 
patient's  pulse  pressure  and  risk  of  cardiovas- 
cular complications.  Domanski  et  al4  have  re- 
cently demonstrated  an  11%  increase  in  stroke 
risk  and  a 16%  increase  in  risk  of  all  cause  mor- 
tality for  each  10  mm  Hg  increase  in  the  pulse 
pressure. 

In  conclusion,  systolic  hypertension  is  now 
recognized  as  more  frequent  and  more  impor- 
tant than  diastolic  among  the  large  majority  of 
hypertensive  patients.  Treatment  that  does  not 
lower  blood  pressure  to  130/85  mm  Hg  is  inad- 
equate. 

REFERENCES 

1.  SHEP  Cooperative  Research  Group.  Prevention  of 
stroke  by  antihypertensive  drug  treatment  in  older 
persons  with  isolated  systolic  hypertension:  final 
results  of  the  Systolic  Hypertension  in  the  Elderly 
Program  (SHEP).  JAMA  1991;265:3255-3264. 

2.  The  sixth  Report  of  the  Joint  National  Committee 
on  Prevention,  Detection,  Evaluation,  and 
Treatment  of  High  Blood  Pressure.  Arch  Intern  Med 
1997;157:2413-2446. 

3.  Lloyd-Jones  DM,  Evans  JC,  Larson  MG,  et  al. 


294  J La  State  Med  Soc  VOL  152  June  2000 


Differential  impact  of  systolic  and  diastolic  blood 
pressure  level  on  JNC-VI  staging.  Hypertension 
1999;34:381-385. 

4.  Domanski  MJ,  Davis  BR,  Pfeffer  MA,  et  al.  Isolated 
systolic  hypertension  prognostic  information 
provided  by  pulse  pressure.  Hypertension 
1999;34:375-380. 


Dr  McMahon  is  Clinical  Professor  of  Medicine, 
Tulane  University  School  of  Medicine  and 
Director,  Clinical  Research  Center, 
New  Orleans,  Louisiana. 

DrFrohlich  is  Editor-in-Chief  of  Hypertension,  a 
journal  of  the  American  Heart  Association. 
He  is  also  an  Alton  Ochsner  Distinguished  Scientist 
at  Alton  Ochsner  Medical  Foundation, 
Professor  of  Medicine  and  Physiology  at 
Louisiana  State  University  School  of  Medicine,  and 
Clinical  Professor  of  Medicine  and 
Adjunct  Professor  of  Pharmacology  at 
Tulane  University  School  of  Medicine, 
New  Orleans,  Louisiana. 


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J La  State  Med  Soc  VOL  152  June  2000  295 


Pathobiological  Determinants  of 
Atherosclerosis  in  Youth  (PDAY) 
Cardiovascular  Specimen  and  Data  Library 

Arthur  W.  Zieske,  MD;  Gray  T.  Malcom,  PhD;  and  Jack  P.  Strong,  MD 


In  1985,  investigators  organized  a multi-center  study,  Pathobiological  Determinants  of  Athero- 
sclerosis in  Youth  (PDAY),  to  examine  the  relationships  of  cardiovascular  risk  factors  to  athero- 
sclerosis involving  more  than  3,000  young  persons  15  through  34  years  of  age  who  died  of  exter- 
nal causes.  Reports  from  the  PDAY  group  confirmed  that  atherosclerosis  begins  in  the  teens  and 
showed  that  the  progression  of  the  lesions  is  strongly  influenced  by  the  same  risk  factors  that 
predict  risk  of  clinically  manifest  coronary  disease  in  middle-aged  adults.  The  results  empha- 
size the  need  for  early  and  aggressive  control  of  all  risk  factors  in  young  persons  for  long-range 
prevention  of  coronary  heart  disease  and  related  diseases.  Recent  funding  by  the  Louisiana 
Cancer  and  Lung  Trust  Fund  (LCLTF)  has  assisted  Pathology  at  Louisiana  State  University  Health 
Sciences  Center  (LSUHSC)  in  the  following  objectives:  (1)  maintaining  this  national  research 
resource;  (2)  making  the  unique  specimens  available  to  interested  investigators;  and  (3)  con- 
tinuing support  for  studies  at  LSUHSC  which  investigate  the  effects  of  smoking  on  the  devel- 
opment of  atherosclerotic  lesions. 


Atherosclerosis  begins  in  childhood  with 
deposits  of  lipid  in  macrophages  and 
smooth  muscle  cells  located  in  the  in- 
tima  of  arteries  to  form  fatty  streaks.1'3  Fatty 
streaks  are  themselves  innocuous  but  in  young 
adulthood  some  progress  to  larger  lipid  depos- 
its with  a fibromuscular  cap  (fibrous  plaques).4"7 
In  middle-aged  individuals,  fibrous  plaques  are 
prone  to  vascularization,  calcification,  hemor- 
rhage, and  rupture  and  predisposed  to  throm- 
bosis, arterial  occlusion,  and  clinically  manifest 
coronary  heart  disease.1 

In  1985,  investigators  organized  a multi-cen- 
ter study,  Pathobiological  Determinants  of  Ath- 
erosclerosis in  Youth  (PDAY),  to  examine  the 
relationships  of  cardiovascular  risk  factors  to 
atherosclerosis  involving  more  than  3,000  young 


persons  15  through  34  years  of  age  who  died  of 
external  causes.  The  project  collected  arteries, 
blood,  and  tissue  from  these  cases  and  measured 
risk  factors  either  directly  (serum  lipoproteins; 
adiposity)  or  by  surrogate  markers  (thiocyanate 
for  smoking;  gly cohemoglobin  for  impaired  glu- 
cose tolerance;  renal  artery  intimal  thickness  for 
hypertension)  in  central  laboratories.  The  De- 
partment of  Pathology  at  Louisiana  State  Uni- 
versity Health  Sciences  Center  (LSUHSC)  has 
been  designated  by  the  National  Heart,  Lung 
and  Blood  Institute  to  centralize,  maintain,  and 
distribute  the  valuable  material  collected  over  a 
7-year  period  from  1987  to  1994  through  the  com- 
bined efforts  of  the  cooperating  institutions.  For 
each  autopsied  subject  there  are  more  than  50 
anatomically  standardized  arterial  samples  pre- 


296  J La  State  Med  Soc  VOL  152  June  2000 


served  in  various  ways,  plus  liver  samples,  heart 
samples,  serum,  and  adipose  tissue.  From  most 
subjects  there  are  quantitative  data  on  major 
known  coronary  heart  disease  (CHD)  risk  fac- 
tors (lipoproteins,  smoking,  hypertension,  dia- 
betes, and  obesity). 

The  PD  AY  Study  is  the  longest  running  and 
most  comprehensive  source  of  information  in  the 
United  States  about  when  heart  disease  begins 
and  progresses  in  young  black  and  white  men 
and  women.  The  cooperating  investigators  have 
published  approximately  100  scientific  reports 
concerning  the  etiology  and  pathogenesis  of  ath- 
erosclerosis in  youth.  These  reports  confirmed 
that  atherosclerosis  begins  in  the  teens  and 
showed  that  the  progression  of  the  lesions  is 
strongly  influenced  by  the  same  risk  factors  that 
predict  risk  of  clinically  manifest  coronary  dis- 
ease in  middle-aged  adults.8'21  The  results  em- 
phasize the  need  for  early  and  aggressive  con- 
trol of  all  risk  factors  in  young  persons  for  long- 
range  prevention  of  coronary  heart  disease  and 
related  diseases.  Now,  the  PD  AY  Archive  makes 
it  possible  to  explore  less  established  risk  fac- 
tors to  atherosclerosis  and  to  evaluate  mecha- 
nisms of  atherogenesis  utilizing  cellular  and 
molecular  pathology  techniques.  The  changes  in 
the  medical,  scientific,  financial,  social,  and  le- 
gal environments  over  the  past  decade  make  it 
impossible  for  a study  that  provides  human  au- 
topsy material,  as  in  this  unique  resource,  to  be 
repeated. 

Establishment  of  the  PDAY  Archive  at 
LSUHSC  began  in  mid-1994.  Recent  funding  by 
the  Louisiana  Cancer  and  Lung  Trust  Fund 
(LCLTF)  has  assisted  the  Pathology  Department 
at  LSUHSC  in  the  following  objectives:  (1)  main- 
taining this  national  research  resource  of  fixed 
and  frozen  specimens  with  accompanying  de- 
mographic data,  CHD  risk  factor  data,  and  ath- 
erosclerotic lesion  data;  (2)  making  the  unique 
specimens  available  to  interested  investigators 
for  current  and  future  studies  in  human  athero- 
sclerosis; and  (3)  continuing  support  for  studies 
at  LSU  which  investigate  the  effects  of  smoking 
on  the  development  of  atherosclerotic  lesions. 

Maintenance  of  the  archive  includes  upkeep 


and  storage  of  fixed  specimens  and  frozen  speci- 
mens which  are  stored  in  ultra-low  temperature 
freezers  equipped  with  C02  back-ups  and 
alarms.  The  inventory  of  specimens  stored  in  the 
Archive  is  continuously  updated. 

Investigators  wishing  to  utilize  resources  in 
the  Archive  must  submit  a request  for  specimens 
and  data  to  Dr  Jack  Strong,  Director  of  the 
Archive  and  Chairman  of  the  Department  of 
Pathology  at  LSUHSC.  The  proposal  is  reviewed 
by  a Utilization  Review  Committee  and,  if  the 
decision  of  the  Committee  is  favorable,  the  spe- 
cific specimens  required  are  selected  and  pre- 
pared for  shipment.  The  investigators  at 
LSUHSC  and  / or  the  Utilization  Committee  will 
collaborate  and/ or  assist  investigators  using  this 
material  in  the  analysis  of  data  and  interpreta- 
tion of  results  as  needed.  Since  mid-1994,  over 
80  favorable  requests  have  been  granted.  Some 
of  the  published  findings  of  these  studies  have 
demonstrated  the  following: 

1 . The  association  of  C pneumoniae  with  athero- 
sclerosis.22 

2.  A description  of  a previously  unknown  hu- 
man leukointegrin.23 

3.  Evidence  that  apoptosis  has  a role  in  ad- 
vanced atherosclerosis.24 

4.  That  Matrix  metalloproteinase  expression  is 
markedly  increased  and  that  an  imbalance 
exists  between  matrix  metalloproteinases 
and  their  inhibitors  in  aortic  disease.25 

5.  That  Japanese  youth  have  a higher  ratio  of 
raised  lesions  / fatty  streaks  when  compared 
to  PDAY  subjects.26 

6.  Data  suggesting  that  15-lipoxygenase  is  en- 
zymatically active  and  may  contribute  to 
early  atherogenesis.27 

7.  That  Galectin-3  expression  is  increased  in 
atherosclerotic  lesions.28 

8.  The  identification  of  two  distinct  patterns  of 
aortic  fatty  streaks  determined  by  the  inter- 
action of  retrograde  with  antegrade  blood 
flow  as  modulated  by  arterial  elasticity.29 

9.  Evidence  that  APO  J has  a protective  effect 
against  atherosclerosis  by  transport  of  cho- 
lesterol from  the  arterial  wall.30 


J La  State  Med  Soc  VOL  152  June  2000  297 


Numerous  other  ongoing  studies  utilizing  PD  AY 
Archive  material  are  in  progress  and  include  the 
role  of  immune  cells  in  the  development  of  ath- 
erosclerosis, the  relationship  between  dental 
plaque  bacterial  species  and  atherosclerosis,  and 
epidemiological  studies  of  immune  markers  of 
modified  LDL  and  atherosclerotic  lesion  char- 
acteristics. 

Support  from  the  Louisiana  Cancer  and 
Lung  Trust  Fund  included  studies  at  LSU  inves- 
tigating the  effects  of  smoking  on  the  develop- 
ment of  atherosclerotic  lesions.  These  studies 
resulted  in  a publication  which  showed  that 
proximal  left  anterior  descending  (LAD)  coro- 
nary artery  sections  from  white  male  smokers 
25-34  years  of  age  have  twice  as  many  advanced 
lesions  and  half  as  many  intermediate  lesions  (a 
type  of  fatty  streak  that  is  raised  and  indicates 
progression  to  an  advanced  lesion)  compared  to 
non-smokers.31  This  observation  suggests  that 
in  smokers  there  is  a rapid  progression  from  in- 
termediate lesions  into  advanced  lesions.  A re- 
cent preliminary  study  using  the  same  subjects 
was  organized  in  order  to  determine  the  asso- 
ciations among  smoking  status,  atherosclerotic 
lesion  types,  and  deposits  of  advanced  gly cation 
end  products  (AGEs)  in  lesions. 

AGEs  are  irreversible,  late  rearrangements 
of  non-enzymatic,  covalent  modification  of  pro- 
teins, lipids,  and  DNA.  Investigators  have  dem- 
onstrated that  AGEs  accumulate  during  the  nor- 
mal aging  process  as  well  as  in  diabetics  and  the 
associated  changes  include  quenching  of  nitric 
oxide,  coagulopathy,  formation  of  oxidized  LDL, 
increased  cell  proliferation,  and  increased  ma- 
trix accumulation,  all  of  which  are  hallmarks  of 
atherogenesis.32'35  These  cellular  responses  are 
mediated  via  specific  AGE  surface  receptors 
identified  on  monocyte  / macrophages,  endothe- 
lial cells,  fibroblasts,  lymphocytes,  and  smooth 
muscle  cells,  and  some  of  these  responses  are 
associated  with  secretion  of  various  growth  fac- 
tors and  cytokines  resulting  in  abnormal 
growth.36'40 

The  interest  in  AGEs  and  their  relationship 
to  atherosclerotic  cardiovascular  disease  was 
initially  stimulated  by  the  observation  that 


linked  AGE  deposition  in  the  vasculature  to  ac- 
celerated atherosclerosis  in  diabetics.41  The  rela- 
tionship of  AGEs  and  atherosclerosis  in  non-dia- 
betic or  normoglycemic  states  has  only  recently 
been  explored.  The  observations  that  AGEs  ac- 
cumulate in  aortic  atherosclerotic  lesions  of  in- 
dividuals without  a history  of  diabetes42, 43  sug- 
gest the  possibility  of  AGEs  as  a mediator  in  non- 
diabetic, normoglycemic  atherogenesis.  Recent 
studies  have  shown  that  reactive  gly  cation  prod- 
ucts are  present  in  aqueous  extracts  of  tobacco 
and  in  tobacco  smoke  in  a form  that  can  rapidly 
react  with  proteins  to  form  AGEs  and  that  smoke 
distillate  incubated  in  collagen-coated  microtiter 
wells  demonstrated  AGE  modifications  that 
could  be  inhibited  by  aminoguanidine.44 

The  preliminary  study  demonstrated  that 
AGE  deposits  were  more  extensive  in  advanced 
lesions  when  compared  to  intermediate,  early, 
and  no  lesions  and  that  a trend  for  an  increased 
prevalence  of  lesions  with  greater  than  50%  cells 
or  extracellular  area  immunoreactive  for  AGEs 
was  observed  in  smokers  when  compared  to 
non-smokers.  These  observations  suggest  that 
AGEs  may  be  involved  in  a progression  of  in- 
termediate lesions  into  advanced  lesions  and 
implicate  AGEs  in  smoking-related  atherogen- 
esis. 

These  data  indicate  that  smoking  has  a dra- 
matic effect  on  atherogenesis  in  the  coronary 
arteries  in  white  male  smokers,  that  clinically 
vulnerable  lesions  may  appear  earlier  on  and  are 
more  prevalent  in  smokers  than  in  non-smok- 
ers, and  support  a role  for  AGEs  in  the  progres- 
sion of  atherosclerosis  associated  with  smoking. 
The  above  microscopic  studies  on  white  males 
will  be  extended  to  black  males  and  black  and 
white  females  in  order  to  determine  the  interac- 
tions between  age,  race,  gender,  lesion  type,  AGE 
deposition,  and  smoking  on  coronary  arteries  in 
young  subjects.  These  microscopic  studies  will 
have  significant  implications  for  prevention  of 
atherosclerosis  in  young  people  and  on  the  un- 
known mechanisms  by  which  smoking  affects 
atherosclerosis. 

The  long-term  primary  prevention  of  coro- 
nary heart  disease  and  other  diseases  related  to 


298  J La  State  Med  Soc  VOL  152  June  2000 


atherosclerosis  is  a major  public  health  concern 
for  the  United  States  and  the  world.  The  PD  AY 
Archive  will  certainly  play  a role  in  the  devel- 
opment of  future  guidelines  that  support  the 
efforts  to  prevent  the  development  of  coronary 
heart  disease  starting  with  young  people.  With 
support  from  the  Louisiana  Cancer  and  Lung 
Trust  Fund,  the  PD  AY  Archive  will  continue  to 
be  a valuable  resource  for  researchers  in  Louisi- 
ana as  well  as  other  national  and  international 
investigators  interested  in  the  pathogenesis  and 
prevention  of  atherosclerosis. 

ACKNOWLEDGMENTS 

Supported  in  part  by  grants  HL33746,  HL45720, 
and  HL60808  awarded  by  the  National  Heart, 
Lung  and  Blood  Institute,  National  Institute  of 
Health,  Bethesda,  Maryland  and  by  LCLTFB  98- 
0X-01  awarded  by  the  Louisiana  Cancer  and 
Trust  Fund  Board,  New  Orleans,  Louisiana. 

REFERENCES 

1 . Strong  IP,  McGill  HC  Jr.  The  natural  history  of  coro- 
nary atherosclerosis.  Am  J Pathol  1962;40:37-49. 

2.  Stary  HC.  Evolution  and  progression  of  atheroscle- 
rotic lesions  in  coronary  arteries  of  children  and 
young  adults.  Arteriosclerosis  1989;9(suppl  I):I19-I32. 

3.  McGill  HC  fr,  Geer  JC,  Strong  JP.  Natural  history  of 
human  atherosclerotic  lesions.  In:  Sandler  M, 
Bourne  GH  (editors)  Atherosclerosis  and  Its  Origin. 
New  York,  NY:  Academic  Press;  1963:39-65. 

4.  Robertson  WB,  Geer  JC,  Strong  IP,  et  al.  The  fate  of 
the  fatty  streak.  Exp  Mol  Pathol  1963;l(suppl):28-39. 

5.  Geer  JC,  McGill  HC  Jr,  Robertson  WB,  et  al.  Histo- 
logic characteristics  of  coronary  artery  fatty  streaks. 
Lab  Invest  1968;18:565-570. 

6.  Stary  HC,  Chandler  AB,  Glagov  S,  et  al.  A defini- 
tion of  initial,  fatty  streak,  and  intermediate  lesions 
of  atherosclerosis:  a report  from  the  Committee  on 
Vascular  Lesions  of  the  Council  on  Arteriosclero- 
sis, American  Heart  Association.  Circulation. 
1994;89:2462-2478. 

7.  Stary  HC,  Chandler  AB,  Dinsmore  RE,  et  al.  A defi- 
nition of  advanced  types  of  atherosclerotic  lesions 
and  a histological  classification  of  atherosclerosis: 
a report  from  the  Committee  on  Vascular  Lesions 
of  the  Council  on  Arteriosclerosis,  American  Heart 
Association.  Arterioscler  Thromb  Vase  Biol 
1995;15:1512-1531. 


8.  Strong  JP,  Malcom  GT,  McMahan  CA,  et  al  (for  the 
Pathobiological  Determinants  of  Atherosclerosis  in 
Youth  Research  Group).  Prevalence  and  extent  of 
atherosclerosis  in  adolescents  and  young  adults. 
Implications  for  prevention  from  the  Pathobiolog- 
ical Determinants  of  Atherosclerosis  in  Youth  Study. 
JAMA  1999;281:727-735. 

9.  Pathobiological  Determinants  of  Atherosclerosis  in 
Youth  (PDAY)  Research  Group.  Natural  history  of 
aortic  and  coronary  atherosclerotic  lesions  in  youth: 
findings  from  the  PDAY  study.  Arterioscler  Thromb 
Vase  Biol  1993;13:1291-1298. 

10.  Cornhill  JF,  Herderick  EE  (for  the  Pathobiological 
Determinants  of  Atherosclerosis  in  Youth  (PDAY) 
Research  Group).  Arterial  disease  in  young  people. 
In:  Blankenhorn  DH  (editor).  Atherogenesis  and  Re- 
gression. Part  1.  Development  of  Atherosclerosis.  New 
York:  Cahners  Healthcare  Communications;  1993:4- 
10. 

11.  A preliminary  report  from  the  Pathobiological  De- 
terminants of  Atherosclerosis  in  Youth  (PDAY)  Re- 
search Group.  Relationship  of  atherosclerosis  in 
young  men  to  serum  lipoprotein  cholesterol  con- 
centrations and  smoking.  JAMA  1990;264:3018-3024. 

12.  Strong  JP  (for  the  Pathobiological  Determinants  of 
Atherosclerosis  in  Youth  (PDAY)  Research  Group). 
Natural  history  and  risk  factors  for  early  human 
atherogenesis.  Clin  Chem  1995;41:134-138. 

13.  McGill  HC  Jr,  McMahan  A,  Malcom  GT,  et  al.  Ef- 
fects of  serum  lipoproteins  and  smoking  on  athero- 
sclerosis in  young  men  and  women.  Arterioscler 
Thromb  Vase  Biol  1997;17:95-106. 

14.  Malcom  GT,  Oalmann  MC,  Strong  JP.  Risk  factors 
for  atherosclerosis  in  young  subjects:  the  PDAY 
Study.  Ann  NY  Acad  Sci  1997;817:179-188. 

15.  Strong  JP,  Malcom  GT,  Oalmann  MC.  Pathobiologi- 
cal Determinants  of  Atherosclerosis  in  Youth 
(PDAY)  Research  Group.  Environmental  and  ge- 
netic risk  factors  in  early  human  atherogenesis:  les- 
sons from  the  PDAY  study.  Pathol  Internat 
1995;45:403-408. 

16.  Strong  JP,  Malcom  GT,  Oalmann  MC,  (for  the  PDAY 
Research  Group).  The  PDAY  Study:  natural  history, 
risk  factors,  and  pathobiology.  Ann  NY  Acad  Sci 
1997;811:226-237. 

17.  McGill  HC  Jr,  McMahan  AC,  Malcom  GT,  and  the 
Pathobiological  Determinants  of  Atherosclerosis  in 
Youth  (PDAY)  Research  Group.  Relation  of 
glycohemoglobin  and  adiposity  to  atherosclerosis 
in  youth.  Arterioscler  Thromb  Vase  Biol  1995;15:431- 
440. 

18.  McGill  HC  Jr,  Strong  JP,  Tracy  RE,  McMahan  CA, 
Oalmann  MC,  and  the  Pathobiological  Determi- 
nants of  Atherosclerosis  in  Youth  (PDAY)  Research 


J La  State  Med  Soc  VOL  152  June  2000  299 


Group.  Relation  of  a postmortem  renal  index  of  hy- 
pertension to  atherosclerosis  in  youth.  Arterioscler 
Thromb  Vase  Biol.  1995;15:2222-2228. 

19.  Wissler  RW,  Hiltscher  L,  Oinuma  T.  The  lesions  of 
atherosclerosis  in  the  young  from  fatty  streaks  to 
intermediate  lesions.  In:  Fuster  V,  Ross  R,  Topol  EJ 
(editors).  Atherosclerosis  and  Coronary  Artery  Disease. 
Philadelphia:  Lippincott-Raven;  1996:475-489. 

20.  McGill  HC  Jr,  McMahan  CA,  Herderick  EE  (for  the 
PDAY  Research  Group).  Effects  of  coronary  heart 
disease  risk  factors  on  atherosclerosis  of  selected  re- 
gions of  the  aorta  and  right  coronary  artery. 
Arterioscler  Thromb  Vase  Biol  (in  press). 

21.  McGill  HC  Jr,  McMahan  CA,  Zieske  AW  (for  the 
Pathobiological  Determinants  of  Atherosclerosis  in 
Youth  (PDAY)  Research  Group).  Association  of  coro- 
nary heart  disease  risk  factors  with  microscopic 
qualities  of  coronary  atherosclerosis  in  youth.  Cir- 
culation (in  press). 

22.  Kuo  C-C,  Grayston  JT,  Campbell  LA,  Goo  YA,  et  al. 
Chlamydia  pneumoniae  (TWAR)  in  coronary  arter- 
ies of  young  adults  (15-34  years  old).  Proc  Natl  Acad 
Sci  USA  1995;92:6911-6914. 

23.  Van  der  Vieren  M,  Trong  F1L,  Wood  CL,  et  al.  A novel 
leukointegrin,  adB2,  binds  preferentially  to  ICAM- 
3.  Immunity  1995;3:683-690. 

24.  Geng  Y-J,  Libby  P.  Evidence  for  apoptosis  in  ad- 
vanced human  atheroma.  Colocalization  with 
interleukin-lB-converting  enzyme.  Am  J Pathol 
1995;147:251-266. 

25.  Knox  JB,  Sukhova  GK,  Whittmore  AD,  et  al.  Evi- 
dence for  altered  balance  between  matrix 
metalloproteinases  and  their  inhibitors  in  human 
aortic  diseases.  Circulation  1997;95:205-212. 

26.  Komatsu  A,  Sakurai  1.  A study  of  the  development 
of  atherosclerosis  in  childhood  and  young  adults: 
risk  factors  and  the  prevention  of  progression  in 
Japan  and  the  USA.  The  Pathobiological  Determi- 
nants of  Atherosclerosis  in  Youth  (PDAY)  Research 
Group.  Pathol  lnternat  1996;46:541-547. 

27.  Kuhn  H,  Heydeck  D,  Huguo  I,  et  al.  In  vivo  action 
of  15-lipoxygenase  in  early  stages  of  human  athero- 
genesis.  J Clin  Invest  1997;99:888-893. 

28.  Nachtigal  M,  Al-Assaad  Z,  Mayer  EP,  et  al.  Galectin- 
3 expression  in  human  atherosclerotic  lesions.  Am  J 
Pathol  1998;152:1199-1208. 

29.  Sloop  GD,  Perret  RS,  Brahney  JS,  et  al.  A descrip- 
tion of  two  morphologic  patterns  of  aortic  fatty 
streaks  and  a hypothesis  of  their  pathogenesis.  Ath- 
erosclerosis 1998;141:153-160. 

30.  Ishikawa  Y,  Ishii  T,  Akasaka  Y,  et  al  (For  the  PDAY 
Research  Group).  Immunolocalizations  of 
apolipoproteins  in  the  abdominal  aorta  and  the  role 
of  apolipoprotein  J on  atherosclerosis  in  young 


aorta,  (submitted  to  Atherosclerosis). 

31.  Zieske  AW,  Takei  H,  Fallon  KB,  et  al.  Smoking 
and  atherosclerosis  in  youth.  Atherosclerosis 
1999;144:403-408. 

32.  Vlassara  H,  Bucala  R,  Striker  L.  Pathogenic  effects 
of  advanced  glycosylation  endproducts:  biochemi- 
cal, biologic,  and  clinical  implications  for  diabetes 
and  aging.  Lab  Invest  1994;70:138-151. 

33.  Lee  WK,  Bell  J,  Kilpatrick  E,  et  al.  Collagen  linked 
fluorescence  in  human  atherosclerotic  plaques.  Ath- 
erosclerosis 1993;98:219-22 7. 

34.  Bucala  R,  Tracey  KJ,  Cerami  A.  Advanced 
glycosylation  products  quench  nitric  oxide  and  me- 
diate defective  endothelium  dependent  vasodila- 
tation in  experimental  diabetes.  J Clin  Invest 
1991;87:432-438. 

35.  Bucala  R,  Mitchell  R,  Arnold  K,  et  al.  Identification 
of  the  major  site  of  apolipoprotein  B modification 
by  advanced  glycation  endproducts  blocking  up- 
take by  the  low  density  lipoprotein  receptor.  J Biol 
Chem  1995;270:10828-10832. 

36.  Imani  F,  Horii  Y,  Suthanthiran  M,  et  al.  Advanced 
glycosylation  endproduct-specific  receptors  on  hu- 
man and  rat  T-lymphocytes  mediate  synthesis  of 
interferon  gamma:  role  in  tissue  remodeling.  J Exp 
Med  1993;178:2165-2172. 

37.  Vlassara  H.  Recent  progress  on  the  biologic  and 
clinical  significance  of  advanced  glycosylation 
endproducts.  J Lab  Clin  Med  1994;124:19-30. 

38.  Vlassara  H,  Li  YM,  Imani  F,  et  al.  Identification  of 
galectin-3  as  a high  affinity  binding  protein  for  ad- 
vanced glycation  endproducts  (AGE):  a new  mem- 
ber of  the  AGE-receptor  complex.  Mol  Med 
1995;1:634-646. 

39.  Li  YM,  Mitsuhashi  T,  Wojciehowitcz  D,  et  al.  Mo- 
lecular identity  and  cellular  distribution  of  ad- 
vanced glycosylation  endproduct  receptors:  rela- 
tionship of  p60  to  OST-48  and  p90  to  80K-H  mem- 
brane proteins.  Proc  Natl  Acad  Sci  USA 
1996;93:11047-11052. 

40.  Schmidt  AM,  Vianna  M,  Gerlach  M,  et  al.  Isolation 
and  characterization  of  two  binding  proteins  for 
advanced  glycosylation  end  products  from  bovine 
lung  which  are  present  on  the  endothelial  cell  sur- 
face. J Biol  Chem  1992;256:14987-14997. 

41.  Nakamura  Y,  Horii  Y,  Nishino  T,  et  al.  Immunohis- 
tochemical  localization  of  advanced  glycosylation 
endproducts  in  coronary  atheroma  and  cardiac  tis- 
sue in  diabetes  mellitus.  Am  J Path  1993;143:1649- 
1656. 

42.  Kume  S,  Takeya  M,  Mori  T,  et  al.  Immunohis- 
tochemical  and  ultrastructural  detection  of  ad- 
vanced glycation  end  products  in  atherosclerotic 
lesions  of  human  aorta  with  a novel  specific  mono- 


300  J La  State  Med  Soc  VOL  152  June  2000 


clonal  antibody.  Am  J Path  1995;147:654-667. 

43.  Stitt  AW,  He  C,  Friedman  S,  et  al.  Elevated  AGE- 
modified  apoB  in  sera  of  euglycemic,  normo- 
lipidemic  patients  with  atherosclerosis:  relationship 
to  tissue  AGEs.  Mol  Med  1997;3:617-627. 

44.  Cerami  C,  Founds  H,  Nicholl  I,  et  al.  Tobacco  smoke 
is  a source  of  toxic  reactive  gly cation  products.  Proc 
Natl  Acad  Sci  1997;94:13915-13920. 


Dr  Zieske  is  Assistant  Professor, 
Department  of  Pathology,  Louisiana  State  University 
Health  Services  Center  in  New  Orleans,  Louisiana. 

Dr  Malcom  is  Professor  Emeritus, 
Department  of  Pathology,  Louisiana  State  University 
Health  Services  Center  in  New  Orleans,  Louisiana. 

Dr  Strong  is  Boyd  Professor  and  Head, 
Department  of  Pathology,  Louisiana  State  University 
Health  Sciences  Center  in  New  Orleans,  Louisiana. 

All  authors  have  a major  interest  in  atherosclerosis 
and  coronary  heart  disease  research. 


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J La  State  Med  Soc  VOL  152  June  2000  305 


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Vol.  1 52,  No.  7 


ESTABLISHED  1844 


July  2000 


Of  the  Louisiana  State  Medical  Society 


UNIVERSITY  OF  MARYLAND  AT 
c BALTIMORE 

AUG  29  2000 


NOT  IN  CIRC# 


Meniere  s Disease 


' jj  ISII 


Abnormal  Bone  Survey  in  a Cancer  Patient 
Preventing  and  Managing  Difficult  Patient-Physician  Relationships 
New  Therapies  for  Treating  Hypertension:  What  Every  Physician  Should  Know 
Splenosis  and  the  Gynecologic  Patient:  A Case  Report  and  Review  of  Literature 
Maximizing  Medication  Adherence  in  Low-Income  Hypertensives:  A Pilot  Study 
Joseph  E.  Murray,  MD:  Profound  Achievement  Through  Plastic  Surgery 
ECG  Report  of  the  Month:  Short  Circuit 


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Editor 

CONWAY  S.  MAGEE,  MD 

Chief  Executive  Officer 

DAVE  TARVER 


General  Manager 

CATHY  LEWIS 

Managing  Editor 

ANNE  SHIRLEY 

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LSMS  BOARD  OF  GOVERNORS 
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KEITH  DESONIER,  MD 
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RUSSELL  C.  KLEIN,  MD 
WALLACE  H.  DUNLAP,  MD 
VINCENT  A.  CULOTTA  JR,  MD 
RICHARD  J.  PADDOCK,  MD 
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WILLIAM  T.  HALL,  MD 
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R.  MARK  WILLIAMS,  MD 
MARTIN  B.  TANNER,  MD 
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The  Journal  of  the  Louisiana  State  Medical  Society 

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The  Journal  reserves  the  right  to  make  the  final 
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Of  the  Louisiana  State  Medical  Society 


A c-ro-M  ci 


Dayton  Daberkow  II,  MD 

328 

Preventing  and  Managing  Difficult 
Patient-Physician  Relationships 

Mrugeshkumar  K.  Shah,  MD 
Stephanie  Y.  Hugghins,  BS 
Hunter  C.  Champion,  MD 
Trinity  J.  Bivalacqua,  BS 

334 

New  Therapies  for  Treating  Hypertension: 
What  Every  Physician  Should  Know 

Antonio  R.  Pizarro,  MD 
James  W.  Gallaspy,  MD 
Soheir  Nawas,  MD 
Guillermo  Herrera,  MD 
Remi  Gomila,  MD 

345 

Splenosis  and  the  Gynecologic  Patient: 
A Case  Report  and  Review  of  Literature 

Bradford  W.  Applegate,  PhD 
Steven  C.  Ames,  PhD 
Daniel  J.  Mehan,  Jr,  MS 
G.  Tipton  McKnight,  MD 
Glenn  N.  Jones,  PhD 
Phillip  J.  Brantley,  PhD 

349 

Maximizing  Medication  Adherence  in 
Low-Income  Hypertensives:  A Pilot  Study 

Departments 


308 

Jorge  I.  Martinez-Lopez,  MD  311 

Bradford  A.  Woodworth,  BA  314 

Philip  C.  Fitzpatrick,  MD 
Gerard  J.  Gianoli,  MD 

Maria  Calimano,  MD  321 

Andres  Acosta,  MD 
Harold  Neitzschman,  MD 

Nicole  E.  Rogers,  BA  323 


358 

360 


INFORMATION  FOR  AUTHORS 

ECG  OF  THE  MONTH 
Short  Circuit 

OTOLARYNGOLOGY/HEAD  & NECK 
SURGERY  REPORT 
Meniere’s  Disease 

RADIOLOGY  CASE  OF  THE  MONTH 
Abnormal  Bone  Survey  in  a Cancer  Patient 

HISTORY  OF  MEDICINE 
Joseph  E.  Murray,  MD 

Profound  Achievement  Through  Plastic  Surgery 
CALENDAR 

CLASSIFIED  ADVERTISING 


J La  State  Med  Soc  VOL  152  July  2000  307 


Information  for  Authors  (expanded) 


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the  first  mention  of  the  expanded  form. 

Units  of  measure  should  be  entered  in  conventional  units.  If  essential, 
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following  the  conventional  expression. 

38°C  3.3  mg/dL  100  mL/hr 

Drug  names  should  be  entered  in  the  generic  form.  If  the  proprietary  name 
is  especially  relevant  to  the  study,  it  may  be  added  in  parentheses  immedi- 
ately following  the  first  mention  of  the  generic  name.  A generic  name  is 
lowercased;  a proprietary  name  is  capitalized. 

Laboratory  procedures  which  are  unusual  should  show  normal  values  in 
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Names  of  organisms  should  include  full  genus  and  species  at  first  mention; 
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capitalize  genus,  lowercase  species;  set  entire  name  italic. 

Statistical  statements  should  have  an  explanation  of  their  meaning  added 
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Citing  a reference  entry  should  be  by  superscript  arabic  numerals  inserted 
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punctuation;  cite  reference  entries  in  the  main  text,  in  tables,  and  in  legends, 
but  not  in  the  abstract. 

Smith1  Brown  et  al2  Several  authors3-4-5  9 


Parts  of  the  Manuscript 

Title  page.  The  title  page  should  carry  the  following  information:  (1)  The 
title  of  the  manuscript,  which  should  be  concise,  clear,  and  informative.  Do 
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study  was  done;  (4)  The  current  institutional  affiliation  of  each  author  if  it 
has  changed;  (5)  Explanatory  notes  that  give:  (a)  a brief  biographical  note 
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Avoid  use  of  acronyms,  abbreviations,  and  initialisms;  do  not  cite  refer- 
ences, tables,  or  figures  (the  abstract  must  stand  alone);  limit  the  abstract  to 
150  words. 

On  the  lower  part  of  the  same  page,  list  three  to  five  key  words  or  short 
phrases  that  will  assist  indexers.  Use  terms  from  Medical  Subject  Headings  as 
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Main  Text.  Avoid  highly  technical  expressions  and  jargon;  the  article  should 
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Use  subheads  freely  to  break  the  typographic  monotony,  make  the  pa- 
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listed  in  the  References  section;  and,  conversely,  all  entries  in  the  References 
section  must  have  been  cited  in  the  main  text,  tables,  or  legends. 

Each  reference  entry  is  composed  of  three  elements. 

A reference  entry  for  an  article  in  a journal  is  composed  of  the  following 
three  elements:  (1)  name  of  author,  (2)  title  of  the  article,  and  (3)  the  loca- 
tion of  the  article. 

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(1)  name  of  author,  (2)  title  of  the  book  or  monograph,  and  (3)  facts  of 
publication. 

Name  of  author  (journal  article  or  book):  Give  last  name,  initials,  senior- 
ity indicator;  list  one,  two,  or  three  authors;  if  more  than  three  authors,  list 
the  first  three  and  follow  with  “et  al”;  separate  the  names  with  commas. 

Title  of  a journal  article:  Capitalize  in  sentence  style. 

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derline to  indicate  that  the  title  is  to  be  printed  italic. 

Publication  data  for  a journal  article:  Give  abbreviated  name  of  journal, 
year  of  publication,  volume  number,  first  and  last  page.  Abbreviate  name  of 
journal  in  accordance  with  style  used  in  List  of  Journals  Indexed  in  Index 
Medicus ; italicize  name  of  journal  or  underline  to  indicate  that  the  name  of 
the  Journal  is  to  be  printed  italic;  do  not  omit  digits  from  first  or  last  page 
numbers. 

Publication  data  for  a book  or  monograph:  City  where  published,  name  of 
publisher,  year  of  publication,  first  and  last  pages. 

The  following  six  examples  illustrate  the  reference  style  adopted  by  the 
Journal  for  (1)  a reference  to  an  article  in  a journal,  (2)  a reference  to  a book 
or  monograph,  (3)  a reference  to  a part  of  a larger  work,  (4)  an  organization 
as  an  author,  (5)  a reference  to  a government  publication,  (6)  a reference  to 
a presentation  at  a societal  meeting,  (7)  a reference  to  an  article  in  a newspa- 


308  J La  State  Med  Soc  VOL  152  July  2000 


Information  for  Authors  (expanded) 


per,  and  (8)  a reference  to  a book  which  has  been  accepted  for  publication 
but  has  not  yet  been  published. 

1.  Brush  JE  Jr,  Cannon  RO  III,  Schenke  WH,  et  al.  Angina  due  to 
coronary  microvascular  disease  in  hypertensive  patients  without 
left  ventricular  hypertrophy.  N Engl  J Med  1988;319:1302-1307. 

2.  Hajdu  SI.  Pathology  of  Soft  Tissue  Tumors.  Philadelphia,  Pa:  Lea  & 
Febiger;  1979:60-83. 

3.  Robinson  BH.  Lactic  acidemia.  In:  Scriver  CR,  Beaudet  AL,  Sly 
WS,  et  al  (editors).  The  Metabolic  Basis  of  Inherited  Disease , 6th 
edition.  New  York:  McGraw-Hill;  1989:869-888. 

4.  American  College  of  Physicians.  Comprehensive  functional 
assesment  of  elderly  patients.  Ann  Intern  Med  1988;109:70-72. 

5.  Office  of  Smoking  and  Health.  The  Health  Consequences  of 
Involuntary  Smoking:  A Report  of  the  Surgeon  General,  1986. 
Rockville,  Md:  US  Department  of  Health  and  Human  Resources; 
1987:97-106  [CDC  publication  87-8398], 

6.  Schacter  RK,  Arluk  J.  Flexural  microflora  in  patients  with  psoriasis. 
Presented  at  the  Annual  Meeting  of  the  American  Academy  of 
Dermatology,  New  Orleans,  La,  December  4-6,  1982. 

7.  Altman  LK.  Experts  change  guides  for  using  drugs  for  HIV.  Hew 
York  Times  June  27,  1993:1,23. 

8.  Levine  S,  Walsh  D,  Amic  B,  et  al  (editors).  Society  and  Health 
Foundations  for  a Nation.  London:  Oxford  University'  Press  [in 
press]. 

Ty'pe  each  reference  entry  as  a separate  hanging  paragraph;  number  the  en- 
tries consecutively  in  the  order  cited;  do  not  list  alphabetically;  double-space 
reference  entries;  and  punctuate  as  shown  in  the  examples  above. 

Limit  references  to  15  unless  special  arrangements  have  been  made  with 
the  editors. 

Personal  communications  and  unpublished  data  should  not  be  cited  or 
entered  in  the  list  of  references,  but,  if  essential,  may  be  integrated  paren- 
thetically with  the  text. 

The  authors  are  responsible  for  the  accuracy  of  the  citations  and  the 
reference  entries.  The  authors  are  expected  to  have  read  and  verified  all  of 
the  listed  references. 

Tables.  A table  consists  of  a caption  (table  number  and  title),  the  body  of 
the  table,  and  footnotes.  Tables  should  be  self-explanatory  and  should  supple- 
ment, not  duplicate,  the  main  text.  All  tables  should  have  been  referred  to  in 
the  main  text. 

Type  each  table  on  a separate  page;  number  tables  in  the  order  first 
cited;  provide  a title;  avoid  vertical  rules;  consult  recent  issues  of  The  Journal 
for  examples. 

Limit  tables  to  one  table  (or  one  figure)  per  1000  words  of  text. 

Illustrations 

Illustrations  include  graphs,  charts,  maps,  line  drawings,  photographs,  and 
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All  illustrations  should  have  been  referred  to  in  the  text.  An  illustration 
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ity7, may  be  acceptable  at  the  option  of  the  editors).  Four-color  illustrations 
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Affix  a label  to  the  back  of  each  illustration  listing  the  figure  number,  the 
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Limit  illustrations  to  one  figure  (or  one  table)  per  1000  words  of  text; 
consult  recent  issues  of  the  Journal  for  examples  of  figures.  Number  the 
figures  in  the  order  first  cited  in  the  text. 

Legends.  A legend  consists  of  a figure  number,  a description  of  the  figure, 


an  explanation  of  any  notations  on  the  figure,  the  techniques  used,  and  an 
acknowledgment  of  the  source  if  the  figure  has  been  previously  published. 
Ty'pe  all  legends  on  a separate  sheet;  use  block  paragraphs. 

Cover  Letter 

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Permissions 

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the  Editor  Dr  Magee  at  (337)  439-8450,  Fax  (337)  439-7576;  E-mail: 
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Final  Check 

All  authors  are  expected  to  have  read  the  final  draft  of  the  manuscript  before 
it  is  submitted.  The  corresponding  author  will  be  responsible  for  the  validity7 
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Submission  of  the  Manuscript 

Submit  the  manuscript  (in  triplicate),  the  illustrations  (two  copies  each),  the 
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Editor 

Journal  of  the  Louisiana  State  Medical  Society 
6767  Perkins  Road 
Baton  Rouge,  LA  70808 


J La  State  Med  Soc  VOL  152  July  2000  309 


This  year,  w celebrate  our  10th  anniversary. 


Although  our  roots  reach  back  to  the  1930's,  The  Trust  Company 
of  Louisiana  celebrates  its  10th  anniversary  this  year-operatmg 
as  an  independent  trust  company.  Our  independence  makes  us 
unique,  because  we  focus  on  serving  our  clients  and  answer  only 
to  our  owners- who  also  happen  to  be  our  employees. 

The  Trust  Company  began  as  a small  firm  with  just  over  $60 
million  in  trust  assets,  offering  trust  services  solely  to 


north  Louisiana  clients.  Now  with  1 1 offices  statewide,  we  manage 
$550  million  in  trust  assets  and  have  expanded  our  offerings  to 
include  investment  services,  financial  planning,  capital  management 
and  corporate  financial  services. 

The  Trust  Company  of  Louisiana:  Thanks  to  our  valued 

clients,  we’ve  come  a long  way  in  only  ten  short  years. 


The  Trust  Company 
of  Louisiana 

Complete  Investment  and  Trust  Services 


Ruston  • Alexandria  • Baton  Rouge  • Covington  • Houma  • Lafayette  • Lake  Charles  • Minden  • Monroe  • Natchitoches  • Shreveport 


Short  Circuit 

Jorge  I.  Martinez-Lopez,  MD 


A 28-year-old  man  presented  to  the  ER  with  ill-defined,  intermittent,  left  anterior  thoracic 
pain  for  about  1 week.  The  patient  was  taking  insulin  to  control  his  type  I diabetes  mellitus. 
The  12-lead  tracing  shown  below  was  recorded  during  his  short  stay  in  the  ER. 


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What  is  your  diagnosis? 
Elucidation  begins  on  page  312. 


J La  State  Med  Soc  VOL  152  July  2000  311 


ECG  of  the  Month 
Presentation  is  on  page  311. 

DIAGNOSIS  - Ventricular  preexcitation 

The  tracing  shows  a regular  rhythm  at  66  times  a 
minute.  Each  QRS  complex  is  preceded  by  a P 
wave  of  normal  morphology,  such  that  the  basic 
rhythm  is  sinus. 

QRS  complexes  are  wide  and  measure  0.12 
sec.  These  wide  complexes  could  be  interpreted 
as  representing  right  bundle  branch  block  or  right 
ventricular  hypertrophy  or — because  they  are 
positively-oriented  in  all  of  the  precordial  leads — 
could  probably  be  classified  as  an  indeterminate 
type  of  defective  intraventricular  conduction. 
More  on  this,  later. 

Another  important  finding  relates  to  the  PR 
interval:  it  is  short  and  measures  approximately 
0.10  sec.  In  the  precordial  leads,  especially  from 
Vj  through  V4,  the  wide  QRS  complexes  rise  di- 
rectly from  the  end  of  the  P wave,  eliminating 
the  PR  segment,  and  are  deformed  by  a broad 
slur  on  the  upstroke  of  the  R wave. 

Taken  together,  the  short  PR  interval,  the  wide 
QRS  complexes,  and  the  broad  slur  on  the 
upstroke  of  the  R waves  in  the  precordial  leads 
(the  so-called  delta  wave)  are  characteristic  ECG 
features  found  in  individuals  with  ventricular 
preexcitation  (VPE);  the  eponymic  designation  for 
this  electrophysiological  event  is  the  Wolff- 
Parkinson-White  (WPW)  pattern. 

Normally,  supraventricular  impulses  can 
only  reach  the  ventricles  to  depolarize  them  by 
crossing  the  AV  node  and  bundle  of  His.  For  VPE 
to  occur,  one  or  more  alternate  routes  of  conduc- 
tion into  the  ventricle(s)  must  be  present.  The  ma- 
jority of  these  accessory  pathways  (AP)  are  found 
around  the  circumference  of  the  AV  rings.  Elec- 
trophysiologically,  they  behave  as  short-circuits 
that  bypass  the  normal  delay  in  conduction  met 
at  the  AV  node  by  supraventricular  impulses  and 
directly  link  the  atrium  to  its  corresponding  ven- 
tricle. In  a small  number  of  individuals,  short- 
circuits  are  located  in  sites  other  than  the  AV 
rings.  The  AP  can  also  be  an  anatomic  substrate 


for  reentry  type  of  arrhythmias. 

When  supraventricular  impulses,  partially 
or  totally,  bypass  the  normal  AV  conducting 
system  and  prematurely  depolarize  a part  or 
all  of  the  ventricular  myocardium,  alterations 
are  found  on  the  surface  ECG.  The  resultant 
QRS  morphology  and  the  degree  of  VPE  are 
dependent  on  the  relative  conduction  velocities 
over  the  AP  and  the  normal  AV  conducting  sys- 
tem as  well  as  the  relationship  of  the  supraven- 
tricular impulse  origin  to  the  location  of  the  AP. 

In  most  instances,  the  resultant  QRS  mor- 
phology represents  a fusion  complex:  premature 
depolarization  of  ventricular  muscle  by  a su- 
praventricular impulse  crossing  the  AP  causes 
the  delta  wave  to  appear;  the  terminal  portion 
of  the  ventricular  complex  represents  depolar- 
ization of  the  ventricles  by  the  same  supraven- 
tricular impulse  by  way  of  the  normal  conduc- 
tion system.  Some  individuals  with  accessory 
pathways,  however,  may  have  normal  (ie,  no 
WPW  pattern)  or  near-normal  QRS  morphol- 
ogy. Supraventricular  impulses  that  travel 
solely  down  the  AP  will  be  associated  with  a 
'Tull-blown"  preexcitation  QRS  morphology. 
Another  factor  to  consider  is  that  coexisting 
cardiac  abnormalities,  such  as  myocardial  in- 
farction and  left  ventricular  hypertrophy,  can 
introduce  additional  alterations  in  QRS  mor- 
phology. 

Although  the  WPW  pattern  is  often  an  inci- 
dental finding,  it  is  important  to  recognize  it 
for  several  reasons.  First,  the  pattern  is  a marker 
for  individuals  who  are  prone  to  develop  a va- 
riety of  supraventricular  tachyarrhythmias 
(WPW  syndrome).  Most  patients  with  the  WPW 
pattern  are  asymptomatic  and  have  an  excel- 
lent long-term  prognosis,  but  those  with  WPW 
syndrome  are  often  symptomatic.  A minority 
of  patients  with  the  syndrome  may  develop 
atrial  fibrillation,  which  may  degenerate  into 
ventricular  fibrillation  and  end  in  death. 

Second,  although  the  WPW  pattern  is  found 
primarily  in  subjects  with  structurally  normal 
hearts,  the  pattern  is  often  found  in  patients 
with  Ebstein's  anomaly  and  in  mitral  valve  pro- 
lapse. For  this  reason,  it  is  incumbent  upon  phy- 


312  J La  State  Med  Soc  VOL  152  July  2000 


sicians  to  exclude  these  two  conditions  as  well 
as  any  other  coexisting  cardiac  disease. 

This  tracing  was  selected  to  illustrate  a third 
important  reason  for  recognizing  the  WPW  pat- 
tern. The  delta  wave  constitutes  the  first  part  of 
the  QRS  complex  during  VPE.  In  any  given  lead, 
or  set  of  leads,  the  delta  wave  may  be  oriented 
positively  (upward  deflection)  or  negatively 
(downward  deflection);  its  polarity  is  dependent 
upon  the  location  of  the  AP.  As  stated  earlier, 
positive  delta  waves,  especially  in  the  precordial 
leads,  may  be  misinterpreted  as  right  or  left 
bundle  branch  block,  defective  intraventricular 
conduction,  or  right  or  left  ventricular  hypertro- 
phy. 

In  this  tracing,  an  additional  finding  is  the 
presence  of  deep  and  broad  Q waves  in  leads  II, 
III,  and  AVF  (inferior  leads).  These  Q waves  are 
actually  negative  delta  waves;  misinterpretation 
of  the  negative  delta  waves  as  pathologic  Q 
waves  might  well  lead  to  the  incorrect  diagno- 
sis of  a remote  inferior  wall  myocardial  infarc- 
tion. Pseudo-infarction  patterns  may  also  occur 
when  negative  delta  waves  are  recorded  in  V 
alone  or  in  Vl  through  V4.  Erroneous  diagnosis 
can  lead  to  inappropriate  and  unnecessary  treat- 
ment. 

The  WPW  pattern  was  accurately  recognized 
in  the  ER.  The  patient's  complaint  of  chest  pain 
was  thought  to  have  a "musculoskeletal"  origin, 
for  which  he  was  given  symptomatic  treatment 
and  reassurance.  Because  he  had  never  experi- 
enced supraventricular  tachyarrhythmias  (ie,  no 
WPW  syndrome),  treatment  directed  at  the  ab- 
normal ECG  pattern  was  neither  justified  nor  in- 
dicated. 


Dr  Martinez-Lopez  is  a specialist  in  cardiovascular 
diseases  affiliated  with  the  Cardiology  Service,  Depart- 
ment of  Medicine,  Texas  Tech  University  Health  Sciences 
Center  and  Thomason  General  Hospital  in  El  Paso,  Texas. 


'■'tolary  loloqy / 

a#  %#’  %»#  ssF 

Head  and  'eck  Surqery 

%s# 


Meniere’s  Disease 

Bradford  A.  Woodworth,  BA;  Philip  C.  Fitzpatrick,  MD;  Gerard  J.  Gianoli,  MD 


Meniere's  disease  is  an  idiopathic  disorder  of  the  inner  ear  characterized  by  the  syndrome 
of  endolymphatic  hydrops,  episodic  vertigo,  fluctuating  hearing  loss,  tinnitus,  and  aural 
fullness.  People  with  this  disorder  may  be  severely  disabled.  Medical  therapy  exists  in  the 
form  of  diuretics  and  dietary  restriction  of  salt  to  minimize  the  fluid  pressure  in  the  laby- 
rinth and  cochlea.  Treatment  of  allergies  with  desensitization  and  steroids  has  also  shown 
to  be  effective  in  selected  patients.  Surgical  therapies  exist  in  two  categories,  conservative 
and  ablative.  Endolymphatic  sac  decompression  with  or  without  shunt  placement  remains 
highly  effective  and  we  feel  that  it  should  be  the  first  line  surgical  therapy  for  patients  who 
fail  medical  therapy.  Ablative  therapies  include  labyrinthectomy  (medical  or  surgical)  and 
vestibular  neurectomy.  Both  of  these  procedures  control  the  episodic  vertigo  by  destroying 
vestibular  function  in  the  affected  ear  and  should  be  reserved  for  patients  who  have  persis- 
tent vertigo  in  spite  of  more  conservative  treatments. 


Meniere's  disease  is  often  a severely 
disabling  disease  of  the  inner  ear.  It 
is  characterized  by  the  syndrome  of 
endolymphatic  hydrops,  also  known  as 
Meniere's  syndrome.  The  symptoms  of 
Meniere's  syndrome  are  varied  and  subjective 
and  often  difficult  to  measure,  so  reports  of  the 
disease  have  to  be  met  with  some  solid  criteria. 
According  to  the  guidelines  from  the  1995  Com- 
mittee on  Hearing  and  Equilibrium  on  diagno- 
sis and  evaluation  of  therapy,  the  syndrome  of 
endolymphatic  hydrops  is  defined  as  two  or 
more  spontaneous  episodes  of  vertigo  20  min- 
utes or  longer,  audiometrically  documented 
hearing  loss  on  at  least  one  occasion,  and  tinni- 
tus or  aural  fullness  on  the  affected  side.1  A di- 


agnosis of  Meniere's  disease  is  given  when  no 
etiology  exists  for  the  hydrops.  It  is  a diagnosis 
of  exclusion. 

Since  Prosper  Meniere  first  described  the 
disease  in  1861,  great  advancements  have  been 
made  in  the  treatment  of  the  disease.  However, 
no  definitive  course  of  action  exists  because 
many  of  these  treatments  remain  varied  and 
controversial.  Conservative  and  non-invasive 
treatments  are  usually  first-line  options  for  any 
disease.  A physician  can  explore  these  options 
with  a patient  while  turning  to  more  radical 
and  invasive  procedures  when  these  treat- 
ments fail.  Meniere's  disease  exists  as  a long, 
protracted  course  that  may  be  amenable  to 
medical  therapy.  Surgical  treatment  options 


314  J La  State  Med  Soc  VOL  152  July  2000 


should  be  reserved  for  intractable  cases.  Abla- 
tive therapies  for  Meniere's  disease  attempt  to 
control  vertigo,  the  most  physically  disabling 
part  of  the  disease,  by  surgically  or  chemically 
destroying  the  labyrinth  or  by  severing  the 
vestibular  nerve  at  the  cerebello-pontine  angle. 
Ablative  treatments  destroy  function  to  allevi- 
ate symptoms,  while  other  surgical  treatments, 
such  as  endolymphatic  sac  decompression,  at- 
tempt to  control  or  minimize  symptoms  by 
targetting  the  underlying  pathophysiology  and 
conserving  function. 

SYMPTOMATOLOGY  AND  EPIDEMIOLOGY 

Meniere's  disease  has  a predilection  for  middle 
age  females  but  can  affect  people  of  all  ages. 
Many  dietary  factors  can  exacerbate  symptoms, 
such  as  excess  salt,  caffeine,  and  smoking.  Ver- 
tigo, the  most  disabling  physical  symptom,  is 
usually  acute  and  may  be  followed  by  asymp- 
tomatic periods  in  between  episodes.  This  ver- 
tiginous episode  usually  lasts  from  30  minutes 
to  several  hours  and  may  be  followed  by  a pe- 
riod of  imbalance  that  can  last  several  days.  An 
acute  attack  can  be  accompanied  by  nausea  and 
vomiting  and  is  often  prostrating.  Patients  may 
experience  feelings  of  pressure  in  the  affected 
ear  before  an  acute  attack  of  vertigo  while  tinni- 
tus may  occur  before,  during,  or  after  the  epi- 
sode. A patient  can  be  very  disabled  from  the 
unpredictability  of  attacks.  This  may  create  anxi- 
ety and  panic  causing  an  emotional  component 
to  the  disease.  Kinney  et  al2  compared  a popu- 
lation of  Meniere's  patients  to  a validity  study 
of  minor  medical  problem  groups  and  major 
medical  problem  groups.  This  study  found  that 
the  physical  symptoms  of  the  Meniere's  patient 
groups  were  more  comparable  to  the  minor 
medical  group  while  the  emotional  disability  of 
the  disease  was  more  comparable  to  the  serious 
medical  group. 

The  natural  progression  of  Meniere's  disease 
consists  of  hearing  loss  that  deteriorates  over 
time.  However,  the  main  hearing  loss  occurs  in 
the  early  stages  of  disease  before  stabilizing.3 
The  hearing  loss  is  usually  most  severe  in  the 
low  frequencies  and  fluctuates  early  in  the 


course  of  the  disease.  As  the  disease  progresses 
the  hearing  loss  becomes  permanent  and  flat 
across  all  frequencies.  Because  of  eventual  re- 
cruitment in  the  cochlea  due  to  hearing  loss, 
noise  intolerance  can  develop  making  it  diffi- 
cult to  fit  many  of  these  patients  with  a hearing 
aid. 

ETIOLOGY  AND  PATHOPHYSIOLOGY 

The  pathophysiologic  state  underlying  Meniere's 
syndrome  is  endolymphatic  hydrops.  Labyrin- 
thitis, congenital  ear  deformities,  trauma  to  the 
ear,  autoimmune  causes,  allergy,  and  infectious 
causes  due  to  mumps  virus  or  syphilis  are 
known  etiologies  of  endolymphatic  hydrops. 
The  syndrome  of  endolymphatic  hydrops  can 
only  be  called  Meniere's  disease  when  the  cause 
of  endolymphatic  hydrops  is  idiopathic  and 
known  causes  have  been  ruled  out.  Other  con- 
ditions that  may  mimic  the  symptoms  of  en- 
dolymphatic hydrops  but  are  not  considered 
part  of  the  syndrome  must  be  ruled  out  as  well. 
Vestibular  neuritis  of  the  recurrent  type  or  re- 
current vestibulopathy  is  characterized  by  epi- 
sodic vertigo  without  the  other  symptoms  of 
endolymphatic  hydrops.  Classic  vestibular  neu- 
ritis may  have  residual  hearing  loss,  tinnitus,  and 
aural  fullness,  but  it  occurs  as  a single  episode 
of  vertigo  that  lasts  several  days.  Cerebello-pon- 
tine angle  tumors,  such  as  acoustic  neuromas, 
may  present  with  a similar  symptom  complex 
and  should  be  ruled  out  with  an  MRI  with  ga- 
dolinium contrast  enhancement.  Otosyphilis 
includes  episodic  vertigo  of  the  Meniere  type, 
hearing  loss,  and  interstitial  keratitis  with  sero- 
logic evidence  of  syphilis  infection.  Cogan's  syn- 
drome is  manifested  by  the  symptoms  of 
otosyphilis,  but  without  serologic  evidence  of  the 
disease.  A variant  of  Cogan's  has  the  added 
symptom  of  uveitis  or  other  ocular  inflamma- 
tion.1 All  of  these  syndromes  must  be  excluded 
to  establish  the  diagnosis  of  Meniere's  disease. 

Several  mechanisms  of  endolymphatic  flow 
in  the  inner  ear  and  the  role  of  the  endolymphatic 
sac  in  the  disease  are  proposed.  A longitudinal- 
flow  theory  propounds  that  endolymph  pro- 
duced by  the  stria  vascularis  in  the  cochlea  flows 


J La  State  Med  Soc  VOL  152  July  2000  315 


longitudinally  to  the  endolymphatic  sac  for  re- 
sorption. Thus,  disruption  or  inflammation  of 
the  sac  may  cause  endolymph  accumulation  re- 
sulting in  endolymphatic  hydrops.  A radial  flow 
theory  proposes  that  endolymph  is  produced 
and  absorbed  by  the  stria  vascularis.  Experimen- 
tal induction  of  hydrops  in  guinea  pigs  by  me- 
chanical obstruction  or  chemical  ablation  of  the 
endolymphatic  duct  supports  the  longitudinal 
flow  theory.  New  evidence  may  suggest  that  the 
endolymphatic  sac  has  resorptive  and  secretive 
properties.  While  it  resorbs  endolymph,  the  sac 
also  secretes  high  osmolar  glycosaminoglycans, 
particularly  hyaluron,  in  response  to  increased 
pressure  in  the  inner  ear.  These  highly  osmotic 
proteins  cause  an  osmotic  shift  of  fluid  from 
surrounding  tissues  and  possible  fluid  shift  from 
the  cochlea  and  vestibule  into  the  sac.  Produc- 
tion of  these  proteins  may  be  a protective  mecha- 
nism for  distention  of  the  inner  ear.  Therefore, 
disruption  of  the  endolymphatic  sac  will  cause 
endolymphatic  hydrops.4 

Several  mechanisms  could  be  responsible  for 
the  actual  vertigo,  which  is  seen  with  hydrops. 
Rupture  of  Reissner's  membrane  due  to 
overdistention  of  the  endolymphatic  compart- 
ment may  allow  mixing  of  the  endolymph  and 
perilymph  resulting  in  vertigo  that  subsides 
when  the  membrane  heals  itself.  Alternatively, 
distention  of  the  membranous  labyrinth  by  ex- 
cess endolymph  may  be  sufficient  to  cause  neu- 
ral discharge  resulting  in  an  acute  attack  that 
subsides  with  alleviation  of  the  distention  and 
pressure.  The  previously  mentioned  theory  on 
excretion  of  high  osmolar  glycoprotiens  by  the 
endolympyhatic  sac  may  contribute  to  symp- 
toms of  acute  vertigo  by  causing  endolymph  to 
flow  rapidly  towards  the  sac  and  thereby  stimu- 
lating hair  cells,  resulting  in  vertigo.4 

Several  theories  are  proposed  on  the  etiol- 
ogy of  Meniere's  disease.  An  immune  etiology 
is  suspected  because  bilateral  features  occur  in 
30%  to  60%  of  cases  when  reviewed  for  long 
periods,  and  a significant  association  with  HLA 
Al,  Cw 7,  B8+-,  DR3  (associated  with  other  au- 
toimmune conditions)  may  point  towards  an 
autoimmune  phenomenon  in  at  least  some  of  the 


patients  with  Meniere's  disease.  Antibodies  re- 
active to  inner  ear  proteins  have  also  been  iden- 
tified in  patients  with  Meniere's  disease.  The 
incidence  of  these  antibodies  was  correlated  with 
disease  activity  and  the  patient's  response  to  ste- 
roids.5 

An  allergic  cause  of  endolymphatic  hydrops 
in  Meniere's  disease  is  another  suspected  etiol- 
ogy. Immunoglobulins  IgG,  IgM,  and  IgA  have 
been  found  in  the  endolymphatic  sac  and  nu- 
merous plasma  cells  and  macrophages  are  con- 
sistently found  in  the  perisaccular  connective 
tissue  of  patients  with  Meniere's  disease.  The 
endolymphatic  sac  has  been  shown  to  process 
and  present  antigen.  Sensitization  to  an  allergen 
or  antigen  may  cause  release  of  IgE  to  bind  mast 
cells  and  result  in  eosinophilic  migration  around 
the  sac,  thereby  causing  inflammation.  The  in- 
tegrity of  the  inner  ear  is  normally  maintained 
by  a blood-labyrinthine  barrier  in  the  labyrin- 
thine artery  that  entails  all  the  restrictions  of  the 
blood-brain  barrier.  However,  the  endolym- 
phatic sac  is  supplied  by  arteriole  branches  from 
the  posterior  meningeal  artery  that  has  a fenes- 
trated endothelium  and  is  not  subject  to  the  tight 
junctions  of  a blood-brain  barrier.  Other  areas 
of  the  body  such  as  the  kidney  that  have  fenes- 
trations are  normally  quite  susceptible  to  the 
inflammatory  effects  of  immune-complex  me- 
diated injury.6  Several  mechanisms  of  hypersen- 
sitivity mediated  injury  have  been  proposed. 
Either  the  sac  itself  could  be  the  target  organ  of 
the  allergic  reaction  or  immune  complexes  could 
be  deposited  through  the  fenestrated  endothe- 
lium of  the  posterior  meningeal  arterioles  pro- 
ducing inflammation  in  the  sac  resulting  in  hy- 
drops. An  increase  in  immune  complexes  has 
already  been  described  in  Meniere's  disease.  In 
an  alternative  mechanism,  immune  complexes 
deposit  in  the  stria  causing  the  intact  blood-laby- 
rinthine barrier  in  the  inner  ear  to  leak.  An  alter- 
native mechanism  involves  a viral  antigen  in- 
teraction with  an  allergic  condition  in  the  de- 
velopment of  the  disease.  For  example,  a pre- 
disposing viral  infection  from  mumps  or  her- 
pes may  cause  long-term  low-grade  inflamma- 
tion that  results  in  full-blown  endolymphatic 


316  J La  State  Med  Soc  VOL  152  July  2000 


hydrops  when  the  patient  is  subjected  to  a physi- 
ologic insult  such  as  allergy  or  metabolic  dys- 
function.6 

TREATMENT 

Controversy  surrounds  the  treatment  of 
Meneire's  disease  because  it  is  difficult  to  deter- 
mine improvement  due  to  the  natural  history  of 
the  disease.  Patients  can  actually  have  a plateau 
in  the  severity  of  their  symptoms  and  some  may 
even  improve  without  treatment.  Medical 
therapy  remains  the  first  line  treatment  in 
Meneire's  disease  because  it  is  conservative  and 
non-invasive.  Some  medical  treatments,  such  as 
diuretics  and  salt  restriction,  attempt  to  decrease 
endolymph  volume  within  the  closed  space  of 
the  inner  ear  and  thereby  alleviate  and  control 
symptoms.  In  addition,  various  individuals  with 
Meneire's  disease  may  respond  to  corticoster- 
oid treatment.  Possible  autoimmune,  allergic,  or 
inflammatory  etiologies  are  reasonable  explana- 
tions for  improvement  in  these  individuals.  De- 
sensitized patients  with  Meniere's  disease  to 
known  allergens  revealed  significant  mitigation 
in  frequency,  severity,  and  interference  with 
daily  activity.  Indications  for  allergy  testing  in- 
clude patients  with  bilateral  symptoms,  inges- 
tion of  a certain  food  or  a change  in  weather  re- 
sulting in  symptoms,  a known  history  of  steroid 
dependent  or  sensitive  symptoms,  or  failure  to 
respond  to  traditional  medical  or  surgical  thera- 
pies for  Meniere's  disease. 

Surgical  treatments  for  intractable  Meniere's 
disease  can  be  either  conservative  or  ablative. 
Conservative  surgery,  as  in  medical  therapy,  at- 
tempts to  relieve  the  pressure  of  excess  en- 
dolymph within  a closed  space.  Performing  a 
conservative,  rather  than  an  ablative  approach, 
first  gives  the  patient  the  option  of  trying  to  save 
their  vestibular  and  auditory  function,  especially 
if  the  disease  is  bilateral,  while  maintaining  the 
possiblity  of  alleviation  of  their  symptoms.  The 
only  real  conservative  surgical  therapy  for 
Meniere's  disease  involves  surgical  decompres- 
sion of  the  temporal  bone  surrounding  the  en- 
dolymphatic sac.  This  involves  drilling  into  the 


mastoid  bone  until  exposure  of  the  endolym- 
phatic sac  is  accomplished.  Removing  the  bony 
encasing  allows  it  flexibility  and  space  to  dis- 
tend freely  and  transmit  pressure  from  within 
the  labyrinth  and  cochlea  to  the  endolymphatic 
sac.  This  surgery  maintains  the  integrity  of  the 
labyrinth  and  vestibular  nerve  and  avoids  an 
open  craniotomy  with  subsequent  risks  of  CSF 
leak  and  meningitis  or  other  serious  intracranial 
infection.  Endolymphatic  sac  decompression  has 
the  advantage  of  not  destroying  vestibular  func- 
tion in  case  the  patient  develops  Meniere's  in 
the  opposite  ear.  In  fact,  more  than  10%  of  people 
with  what  appears  to  be  unilateral  Meniere's 
disease  are  demonstrated  to  have  evidence  of 
endolymphatic  hydrops  in  the  contralateral  ear 
as  demonstrated  by  electrocochleography.7 

A variant  of  sac  decompression,  called  sac- 
vein  decompression,  involves  drilling  out  the 
bone  over  the  endolymphatic  sac,  sigmoid  si- 
nus, and  posterior  cranial  fossa  dura.  Improved 
benefit  over  regular  sac  decompression  and  de- 
compression with  shunt  was  noted  when  the 
sigmoid  sinus  was  included  in  the  decompres- 
sion, particularly  when  patients  had  anterior  and 
medial  displacement  of  the  sigmoid  sinus.  Con- 
trol over  vertigo  and  hearing  stabilization  was 
better  compared  to  normal  decompression  with 
and  without  shunt.8  We  generally  recommend 
this  as  the  first  line  conservative  surgical  treat- 
ment for  treatment  of  Meniere's  disease. 

A variation  on  endolymphatic  sac  decom- 
pression uses  a shunt  placed  into  the  endolym- 
phatic sac  that  drains  endolymph  to  the  mas- 
toid air  space  or  subarachnoid  space  depend- 
ing on  where  the  shunt  is  placed.  However,  his- 
tologic study  of  shunts  has  shown  rapid  over- 
growth of  the  shunt  by  mucosa  within  days  of 
surgery,  acellular  debris  filling  the  vestibule 
around  valves,  and  ingrowth  of  fibrous  tissue 
into  the  sponge.4  In  addition,  there  is  an  associ- 
ated risk  of  severe  hearing  loss  when  opening 
the  sac  for  shunt  purposes.  It  is  for  this  reason, 
also  for  the  fact  that  decompression  without 
shunt  is  highly  effective,  that  we  have  aban- 
doned shunt  placement. 

Since  vertigo  is  the  most  incapacitating 


J La  State  Med  Soc  VOL  152  July  2000  317 


physical  symptom  of  Meniere's  disease,  ablative 
surgical  treatments  attempt  to  treat  this  modal- 
ity. Chemical  or  mechanical  labyrinthectomy  are 
designed  for  this  purpose.  The  inner  ear  hair 
cells  are  susceptible  to  damage  from 
aminoglycoside  toxicity.  These  hair  cells  have 
differential  toxicity  towards  certain  aminogly- 
cosides. Streptomycin  and  gentamicin  are  more 
vestibular  toxic  than  cochlear  toxic.  The  goal  of 
chemical  labyrinthectomy  is  to  administer 
intratympanic  gentamycin  or  streptomycin  to 
ablate  or  lessen  the  vestibular  response  while 
keeping  hearing  damage  to  a minimum.  'Fine 
tuning'  uses  this  therapy  to  diminish  vertigo 
spells  to  the  point  where  they  are  tolerable  but 
not  to  ablate  the  vestibular  response  and  thereby 
keep  hearing  loss  to  a minimum.  Several  tech- 
niques have  been  used  to  increase  the  efficacy 
of  this  therapy.  Hyaluronidase  to  penetrate  soft 
tissue,  gelfoam  insertion  to  prevent  loss  of  medi- 
cation into  the  eustachian  tube,  tympanostomy 
tubes  to  jet  infuse  gentamycin,  coinjecting  dex- 
amethasone  to  reduce  inflammation,  and  buff- 
ered gentamycin  are  all  techniques  to  try  and 
increase  efficacy.  This  procedure  has  the  advan- 
tage of  being  done  in  the  office  with  local  anes- 
thesia and  tailoring  the  treatment  to  fit  the  pa- 
tient. However,  hearing  loss  may  occur  and  pa- 
tients can  experience  imbalance  and  occasional 
severe  prolonged  ataxia  because  this  is  an  abla- 
tive treatment.9 

Ablation  of  vestibular  function  can  also  be 
attained  by  a surgical  labyrinthectomy  using  a 
transmastoid  or  transcanal  approach.  This  inva- 
sive ablative  procedure  mechanically  destroys 
the  labyrinth  but  also  destroys  hearing.  There- 
fore, this  should  only  be  performed  on  patients 
with  unilateral  disease  with  no  serviceable  hear- 
ing. Ablation  of  episodic  vertigo  can  be  achieved 
up  to  100%  with  this  option,  but  post-operative 
imbalance  is  a high  risk  and  leaves  no  function 
if  the  disease  becomes  bilateral.10  Even  though 
this  procedure  controls  episodic  vertigo,  chemi- 
cal labyrinthectomy  is  not  nearly  as  invasive,  can 
be  done  in  the  office,  and  the  patient  is  more 
likely  to  retain  his  hearing. 

Vestibular  neurectomy  is  considered  most 


often  in  a patient  with  intractable  Meniere's  dis- 
ease who  still  has  preserved  hearing.  This  pro- 
cedure involves  entering  the  posterior  cranial 
fossa  via  either  a retrosigmoid  or  retrolabyrin- 
thine  approach  and  clipping  the  vestibular  nerve 
at  the  cerebello-pontine  angle.  Vestibular  neu- 
rectomy is  effective  for  episodic  vertigo  in 
Meniere's  disease  but  is  not  very  useful  in  other 
forms  of  vertigo.  This  procedure  shows  long- 
term control  of  vertigo  approaching  90%,  but 
involves  an  open  craniotomy  with  risks  of  CSF 
leak  and  meningitis  or  other  serious  intracranial 
complication.1 1 

CONCLUSION 

The  physical  and  emotional  symptoms  that  ac- 
company patients  with  Meniere's  disease  are  ex- 
tremely disabling.  If  these  symptoms  cannot  be 
controlled  with  medical  therapy,  then  surgical 
therapy  is  indicated.  Endolymphatic  sac  decom- 
pression without  shunt,  especially  sac-vein  de- 
compression preserves  vestibular  function  and 
allows  the  chance  for  alleviation  or  cure  of  symp- 
toms. If  this  procedure  fails,  the  patient  can  be 
offered  an  ablative  procedure  such  as  vestibular 
neurectomy  or  labyrinthectomy.  It  is  important 
to  help  patients  adapt  to  dysequilibrium  follow- 
ing an  ablative  procedure  and  to  include  reha- 
bilitation if  necessary. 

REFERENCES 

1.  Committee  on  Hearing  and  Equilibrium. 
Committee  on  hearing  and  equilibrium  guidelines 
for  the  diagnosis  and  evaluation  of  therapy  in 
Meniere's  disease.  Otolaryngol  Head  Neck  Surg 
1995;113:181-185. 

2.  Kinney  SE,  Sandridge  SA,  Newman  CW.  Long-term 
effects  of  Meniere's  disease  on  hearing  and  quality 
of  life.  Am  J Otol  1997;18:67-73. 

3.  Quaranta  A,  Onofri  M,  Sallustio  V,  et  al. 
Comparison  of  long-term  hearing  results  after 
vestibular  neurectomy,  endolymphatic  mastoid 
shunt,  and  medical  therapy.  Am  J Otol  1997;18:444- 
448. 

4.  Welling  DB,  Pasha  R,  Roth  LJ,  et  al.  The  effect  of 
endolymphatic  sac  excision  in  Meniere's  disease. 
Am  J Otol  1996;17:278-282. 

5.  Atlas  MD,  Chai  F,  Boscato  L.  Meniere's  disease: 


318  J La  State  Med  Soc  VOL  1 52  July  2000 


evidence  of  an  immune  process.  Am  J Otol 
1998;19:628-631. 

6.  Derebery  MJ.  Allergic  management  of  Meniere's 
disease:  an  outcome  study.  Otolaryngol  Head  Neck 
Surg  2000;122:174-182. 

7.  Cordon  BJ,  Gibson  WPR.  Meniere's  disease:  the 
incidence  of  hydrops  in  the  contralateral 
asymptomatic  ear.  Laryngoscope  1999;109:1800- 
1802. 

8.  Gianoli  G],  Larouere  MJ,  Kartush  JM,  et  al.  Sac- vein 
decompression  for  intractable  Meniere's  disease: 
two-year  treatment  results.  Otolaryngol  Head  Neck 
Surg  1998;118:22-29. 

9.  Blakley  BW.  Clinical  forum:  a review  of  intra- 
tympanic  therapy.  Am  J Otol  1997;18:520-526. 

10.  Langman  AW,  Lindeman  R.  Surgical  laby- 
rinthectomy  in  the  older  patient.  Otolaryngol  Head 
Neck  Surg  1998;  118:  739-742. 

11.  Molony  TB.  Decision  making  in  vestibular  neurec- 
tomy. Am  J Otol  1996;17:421-424. 


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Radiology  Case  of  the  Month 


Abnormal  Bone  Survey  in  a Cancer  Patient 

Maria  Calimano,  MD;  Andres  Acosta,  MD;  Harold  Neitzschman,  MD 


A 34-year-old  woman  presented  with  a history  of  thyroid  carcinoma  who  underwent  a radio- 
graphic  bone  survey  in  search  of  metastatic  disease. 


Figurel . AP  view  of  the  pelvis. 


What  is  your  diagnosis? 
Elucidation  is  on  page  322. 


J La  State  Med  Soc  VOL  152  July  2000  321 


Radiology  Case  of  the  Month 
Case  Presentation  is  on  page  321. 

RADIOLOGIC  DIAGNOSIS  - Osteopoikilosis 

INTERPRETATION  OF  IMAGING 

Figure  1 demonstrates  multiple  small  sclerotic 
foci  involving  both  femoral  heads  and  acetabula. 
The  uniform  appearance  suggests  numerous 
small  islands  of  bone  compatible  with  the  diag- 
nosis of  osteopoikilosis. 

DISCUSSION 

Osteopoikilosis  is  a rare  autosomal  dominant 
bone  disorder  with  slight  male  predominance. 
It  was  first  described  by  Albers-Schonberg  and 
Ledoux-Lebard  in  the  early  20th  century,  and  is 
characterized  by  the  presence  of  multiple,  well- 
circumscribed  round  or  ovoid  areas  of  increased 
bone  density. 

Clinical  manifestations  are  usually  absent. 
When  present,  they  can  consist  of  whitish, 
fibrocollagenous,  infiltrative,  cutaneous  lesions 
(dermatofibrosis  lenticularis  disseminate)  which 
may  be  seen  in  up  to  25%  of  cases.  Another  clini- 
cal manifestation  is  predisposition  to  keloid  for- 
mation.1 It  has  been  associated  with  dwarfism, 
dystonia,  scleroderma,  syndactyly,  and  cleft  pal- 
ate.2 A rare  association  with  osteogenic  sarcoma 
and  plasmacytoma  has  been  reported.3 

Radiographically,  osteopoikilosis  manifests 
as  multiple  small,  well-circumscribed  focal  ar- 
eas of  bony  sclerosis  ranging  in  size  from  2 to  10 
mm.  These  areas  have  a symmetric  distribution 
and  are  predominantly  seen  on  epiphyses  and 
metaphyses  of  long  bones  as  well  as  in  carpal, 
tarsal,  and  membranous  bones.  It  is  thought  that 
these  sclerotic  foci  generally  remain  stable;  how- 
ever, their  disappearance  and  reappearance  has 
been  reported.2  Tc-99m  bone  scan  demonstrates 
no  radiotracer  uptake  in  these  areas.  The  radio- 
logical appearance  and  distribution  permits  a 
confident  diagnosis. 

Histologically,  osteopoikilosis  reflects 
gradual  spongy  bone  remodeling  resulting  from 


mechanical  stress,  without  the  presence  of 
microfractures.  These  changes  are  found  at  in- 
tersections of  spongy  bone  trabeculae.  In  these 
areas,  localized  mechanical  stress  is  reflected  by 
an  increase  of  apatite  crystal  deposition  in  bone.3 

The  main  differential  diagnoses  include  os- 
teoblastic metastases,  melorheostosis,  and  epi- 
physeal dysplasia.  Metastases  will  demonstrate 
increased  uptake  on  a TC-99m  bone  scan. 
Melorheostosis  is  a non-hereditary  condition 
that  can  cause  severe  pain  characterized  by 
" candle  wax  dripping"  appearance  in  a diaphy- 
seal distribution.  Epiphyseal  dysplasia  will  dem- 
onstrate normal  metaphyses,  which  are  com- 
monly involved  sites  in  osteopoikilosis. 

REFERENCES 

1.  Rucker  PT,  Sundaram  M.  Radiologic  case  study. 
Osteopoikilosis.  Orthopedics.  1996;19:357-358. 

2.  Agostinelli  JR.  Osteopoikilosis.  A case  report.  / 
Am  Podiatr  Assoc  1983;73:529-531. 

3.  Lagier  R,  Mbakop  A,  Bigler  A.  Osteopoikilosis:  a 
radiological  and  pathological  study.  Skeletal 
Radiol  1984;11:161-168. 


Drs  Calimano  and  Acosta  are  third-year  residents  at 
Louisiana  State  University  Health  and  Sciences  Center 

in  New  Orleans,  Louisiana. 

Dr  Neitzschman  is  Associate  Professor  of 
Radiology  and  Nuclear  Medicine  at 
Louisiana  State  University  Health  and  Sciences  Center 

in  New  Orleans,  Louisiana. 


322  J La  State  Med  Soc  VOL  152  July  2000 


History  of  Medicine 


Joseph  E.  Murray,  MD 

Profound  Achievement  through  Plastic  Surgery 

Nicole  E.  Rogers,  BA 


Presented  in  part  at  the  annual  meeting  of  the  Tulane 
History  of  Medicine  Society,  March  2000.  This  work 
was  the  recipient  of  the  "Willard  L.  Marmelzat  Foun- 
dation Award"  given  by  the  Tulane  History  of  Medi- 
cine Society. 


Medical  history  contains  a number  of  surgeons 
who  have  contributed  to  the  development  of 
transplantation.  However,  only  one  plastic  sur- 
geon can  be  credited  with  the  first  successful, 
long-lasting,  renal  transplant.  This  is  Dr  Joseph 
E.  Murray,  winner  of  the  1990  Nobel  Prize  for 
Medicine  or  Physiology.  Murray's  interest  in 
plastics  was  pivotal  not  only  in  fueling  his  re- 
search efforts  in  the  area  of  transplantation  but 
also  in  increasing  the  acceptance  and  respect- 
ability of  the  field  as  a whole. 

EDUCATION  AND  EXPERIENCE 

Dr  Murray,  born  in  1919,  lived  at  a time  when 
plastic  surgery  was  still  poorly  defined.  Prior  to 
World  War  I,  doctors  who  might  have  been  con- 
sidered plastic  surgeons  were  actually  prosthetic 


dentists,  oral  surgeons,  ophthalmologists, 
otorhinolaryngologists,  and  general  surgeons 
with  some  experience  in  reconstructive  surgery. 
Trench  warfare  precipitated  the  need  for  physi- 
cians specifically  trained  to  handle  the  terrible 
injuries  to  soldiers'  faces  and  heads  as  well  as 
open  bum  wounds.  Still,  these  doctors  were  not 
recognized  as  plastic  surgeons.  Rather,  they  were 
designated  as  "specialty  teams"  under  the 
Army's  section  on  head  surgery,  and  only  three 
of  such  teams  existed  during  the  First  World 
War.1 

Therefore,  it  was  by  his  chance  involvement 
with  the  Army  during  the  Second  World  War 
that  Murray  became  familiar  with  plastic  sur- 
gery. After  completing  his  training  at  Harvard 
Medical  School  in  1943,  he  was  summoned  to 
Valley  Forge  General  Hospital  in  Phoenixville, 
Pennsylvania.  Valley  Forge  was  one  of  the  eight 
plastic  surgery  centers  that  had  been  established 
by  the  zone  of  the  interior  during  WWTI.2  There, 
while  awaiting  overseas  deployment,  he  was  to 
help  treat  soldiers  with  cranial  and  facial  injuries 
as  well  as  bum  wounds  and  hand  injuries. 


J La  State  Med  Soc  VOL  152  July  2000  323 


Dr  Murray's  excitement  for  plastics  grew  tre- 
mendously while  he  was  at  Valley  Forge.  Hav- 
ing never  before  seen  a skin  graft,  he  faced  an 
enormous  learning  curve.  However,  he  im- 
mersed himself  in  dressings  and  wound  care, 
calling  the  experience  an  "epiphany  of  recon- 
structive surgery".  In  a recent  editorial,  he  re- 
called the  removal  of  post-surgical  dressings  as 
"opening  a present".  The  complexity  of  planning 
a multi-staged  surgical  reconstruction  especially 
thrilled  him.  In  the  three  and  one  half  years  he 
was  there,  he  performed  or  assisted  with  over 
1,800  operations.3  Murray  found  out  years  later 
that  it  was  because  of  his  commitment  and  en- 
thusiasm that  he  was  never  ordered  to  go  over- 
seas.4 

Dr  Murray  was  able  to  learn  a great  deal  from 
physicians  who  were  equally  interested  in  tis- 
sue manipulation  and  reconstruction.  Included 
among  these  were  Lt  Col  James  Barrett  Brown, 
of  Washington  University  Medical  School  in  St 
Louis,  and  1st  Lt  Bradford  Cannon  of  Boston. 
Brown  was  Chief  of  Plastic  Surgery  and  Can- 
non was  Assistant  Chief.  While  scrubbing, 
Murray  had  many  discussions  with  these  men 
about  the  biology  of  tissue  transplantation.  The 
experiences  they  shared  in  skin  homografting 
and  burn  wound  coverage  would  serve  as  the 
necessary  ingredient  for  Murray's  segue  from 
plastics  to  transplantation.5 

Dr  Brown,  twenty  years  his  senior,  had  pre- 
viously done  successful  research  in  split-thick- 
ness skin  grafts  to  cover  large  granulating  sur- 
face areas.  Despite  the  paucity  of  1930's  knowl- 
edge about  genetics  or  immunosuppression. 
Brown  postulated  that  when  skin  was  ex- 
changed between  patients  of  close  relation,  the 
graft  would  have  an  increased  chance  of  sur- 
vival.4 Therefore,  in  order  to  treat  a child  too 
severely  burned  for  autograft  treatment.  Brown6 
transplanted  skin  from  the  mother  until  the 
child's  own  epithelialization  took  over.  These 
grafts  successfully  "took"  for  about  2 weeks  and 
provided  valuable  respite  during  the  child's  re- 
covery. In  the  first  issue  of  the  journal  Surgery 
(1937),  Brown  published  the  results  of  the  first 
permanent  skin  graft  from  one  person  to  another. 


He  did  so  by  using  identical  twins.6  Although 
fraternal  (dizygotic)  twins  are  fairly  common, 
numbering  1 in  90  births,  it  was  fairly  difficult 
for  Brown  to  find  identical  (monozygotic)  twins 
(1  in  270  births)  willing  to  donate  the  time  and 
tissue  for  experimental  cross-transplantation. 
When  he  finally  did  and  found  successful,  per- 
manent incorporation  of  the  grafts,  he  concluded 
that  familial  relation  was  a major  key  to  tissue 
compatibility.7 

RENAL  TRANSPLANTATION 

In  1947,  Murray  returned  to  Boston  with  a new 
interest  in  plastic  surgery.  He  completed  his  gen- 
eral surgical  residency  at  the  Peter  Bent  Brigham 
by  1952  and  a year  of  plastic  surgery  training  in 
New  York  by  1953.  When  he  finally  completed 
his  training  and  returned  to  Boston,  he  was  ea- 
ger to  focus  in  plastics  but  was  encouraged  to 
stay  in  general  surgery,  because  there  seemed  to 
be  little  need  and  because  there  were  already 
established  specialists  at  the  Brigham.3  There- 
fore, Murray  found  other  ways  to  apply  his  in- 
terest in  plastics  to  the  area  of  transplant  biol- 
ogy. He  hypothesized  that  if  the  transplantation 
of  skin  between  identical  twins  was  possible, 
then  the  transplantation  of  other  organs,  such 
as  the  kidney,  would  also  be  possible.  His  re- 
search in  autotransplantation  of  dogs  with  con- 
tralateral nephrectomy  had  been  successful. 
However,  rejection  occurred  when  he  tried  to 
transplant  between  different  dogs.  This  supported 
Brown's  earlier  hypothesis  that  genetics  played  a 
role  in  establishing  tissue  compatibility.8 

Dr  Murray's  opportunity  to  bridge  plastics 
with  transplantation  came  in  December  1954.  A 
24-year-old  white  man  was  suffering  from  acute 
renal  failure,  and  his  identical  twin  was  willing 
to  donate  a kidney  to  him.  In  order  for  the  trans- 
plantation to  work,  and  since  immunosuppres- 
sive drugs  were  not  yet  available,  Murray  had 
to  establish  without  a doubt  that  the  twins  were 
monozygotic.  Most  indications  were  positive, 
such  as  birth  records  of  a single  placenta,  the 
presence  of  the  relatively  rare  Darwin's  tubercle 
on  their  ears  and  identical  structure  and  pigmen- 
tation of  their  eyes.  However,  the  final  decision 


324  J La  State  Med  Soc  VOL  152  July  2000 


to  operate  was  based  on  the  successful  ho- 
motransplantation of  a full-thickness  skin  graft 
between  the  two  brothers.9  In  this  context,  plas- 
tic surgery  fulfilled  a role  that  was  as  important 
as  genome  testing  is  today. 

The  operation  required  creativity  not  only  in 
establishing  tissue  compatibility  but  also  in  es- 
tablishing functional  anatomical  placement  of 
the  new  kidney.  Previously  Drs  Francis  Moore, 
David  Hume,  and  John  Merrill,  also  at  Peter  Bent 
Brigham,  had  placed  cadaveric  kidneys  into 
"pockets"  made  in  the  thigh  skin  of  recipients. 
However,  only  a short  portion  of  the  ureter  re- 
mained vascularized,  necessitating  the  drainage 
of  the  ureter  out  onto  the  skin,  resulting  in  an 
increased  chance  of  ascending  infection.  Re- 
searchers also  had  had  complications  in  anasto- 
mosing the  renal  vessels  with  the  femoral  ves- 
sels in  the  thigh.1 

Dr  Murray  overcame  both  problems  by  plac- 
ing the  new  kidney  retroperitoneally  within  the 
pelvis  and  above  the  bladder,  such  that  the  short 
ureteric  anastomosis  could  lead  directly  down 
to  the  bladder,  using  normal  gravity  conditions. 
He  attached  the  renal  vessels  to  the  iliac  vessels, 
but  reversed  the  normal  anterior-posterior  rela- 
tions of  artery,  vein,  and  ureter  by  installing  the 
kidney  on  the  contralateral  side.  The  heterotopic 
placement  of  the  kidney  also  did  not  cause  as 
much  trauma  as  if  they  had  tried  to  do  a simul- 
taneous removal  of  the  old  kidney  in  order  to 
preserve  the  natural  location. 

Post-operative  results  were  remarkable. 
Three  months  after  the  surgery,  the  patient  de- 
veloped mild  hypertension,  which  dissipated 
with  the  removal  of  the  diseased  left  kidney.  It 
weighed  just  49  grams.  Five  months  post-opera- 
tively,  the  patient  again  developed  hypertension, 
and  the  right  kidney  was  removed  as  well, 
weighing  29  grams.  Both  were  removed  on  the 
premise  that  they  were  no  longer  necessary  for 
normal  renal  function,  and  posed  a risk  for  pos- 
sible infection  in  the  future.  This  sequence  of 
events  serves  as  irrefutable  evidence  that  the 
transplant  had  been  a success.9 

The  next  natural  step  was  to  perform  a trans- 
plant between  non-related  donor  and  recipient. 


However,  this  was  impossible  with  the  tools 
available  at  the  time  for  controlling  immune  re- 
sponse. Steroids,  anticoagulants,  and  x-ray 
therapy  had  all  proven  ineffective.10  Of  the 
twelve  patients  treated  with  total  body  irradia- 
tion, only  one  had  survived,  and  this  was  attrib- 
uted to  the  fact  that  he  and  his  donor  were  dizy- 
gotic twins.11  Murray  worked  with  many  other 
researchers  to  learn  how  to  create  an  immuno- 
suppressive response  in  non-related  transplant 
recipients. 

In  1960,  research  team  members  George 
Hitchings  and  Gertrude  Elion  of  Burroughs 
Wellcome  synthesized  a new  immunosuppres- 
sive drug,  called  azathioprine  (Imuran).8  In  1962, 
Dr  Murray  was  able  to  perform  the  first  success- 
ful kidney  transplant  between  unrelated  donors. 
Despite  its  high  rate  of  toxicity  and  side  effects, 
this  drug  provided  significant  improvements  in 
transplant  success  up  until  the  synthesis  of 
cyclosporine  in  1980. 12 

Dr  Murray's  success  in  applying  plastic  sur- 
gery to  major  organ  transplantation  further  fu- 
eled his  commitment  to  this  newly  developing 
field.  In  a 1982  interview,  Murray  explained  that 
his  primary  passion  was  in  caring  for  children 
with  microtia,  syndactyly,  hypospadias,  or  other 
problems  of  aesthetic  reconstruction.  However, 
there  was  still  not  a formal  plastic  surgery  pro- 
gram in  Boston  in  the  early  1960s.  For  the  first 
10  years  of  Murray's  practice,  any  operations 
alleviating  cleft  palates  or  other  craniofacial  de- 
formities were  done  in  collaboration  with  Dr 
Donald  Matson,  Chief  of  Neurosurgery  at 
Children's  Hospital.3 

It  was  not  until  the  retirement  of  Donald 
McCollum,  attending  plastic  surgeon  at  the 
Brigham  and  Children's  hospitals,  that  Murray 
was  appointed  chief  of  that  division  and  became 
able  to  bring  about  change.5  By  1966,  Murray 
had  succeeded  in  establishing  the  first  plastic 
surgery  residency  in  Boston.  It  grew  up  as  a com- 
bined program  between  Brigham  and  the 
Children's  Hospital  with  Dr  John  Woods  as  the 
first  resident.  Murray  also  remained  active  na- 
tionally as  a member  of  the  Plastic  Surgery  Travel 
Club,  a plastic  surgical  representative  on  the 


J La  State  Med  Soc  VOL  152  July  2000  325 


Forum  Committee  of  the  American  College  of 
Surgeons  (following  Bradford  Cannon),  and  as 
a founding  member  of  the  Plastic  Surgery  Re- 
search Council.2 

NOBEL  PRIZE 

On  October  8,  1990,  Murray  was  bestowed  one 
of  the  most  highly  regarded  titles  in  science: 
Nobel  Laureate,  in  Medicine  or  Physiology,  for 
his  work  in  renal  transplantation.  He  was  the 
first  plastic  surgeon  to  win  the  award,  a full  24 
years  after  any  other  sort  of  surgeon  had  won. 
Three  major  accomplishments  were  recognized, 
including  his  success  with  the  twins  in  1954,  his 
later  success  keeping  a dizygotic  recipient  twin 
alive  using  whole-body  irradiation,  and  finally 
the  transplantation  between  unrelated  individu- 
als using  azathioprine  as  an  immunosuppres- 
sant.8 

Dr  E.  Donnall  Thomas,  who  shared  the 
award  for  his  success  in  the  first  bone  marrow 
transplant  2 years  after  Murray's  work,  com- 
mented, "I  really  thought  our  work  was  too  clini- 
cal to  ever  win  the  prize."  However,  it  fulfilled 
the  criteria  set  forth  in  Alfred  Nobel's  will,  which 
was  that  the  prize  should  be  awarded  "...to 
those  who  during  the  preceding  years  have  af- 
forded the  greatest  benefit  upon  mankind."10 
Murray's  work  alone  has  resulted  in  over  15,000 
kidney  transplantations  in  the  United  States, 
during  1998  and  1999.13 

It  is  therefore  understandable  that  Murray's 
humanitarian  spirit  contributed  largely  to  his 
remarkable  success.  His  father  and  mother,  a 
district  court  judge  and  a schoolteacher,  had  by 
example  emphasized  the  need  for  service  to  oth- 
ers.4 As  an  adult,  Murray  realized  that  scars, 
birthmarks,  and  asymmetric  ears  were  handi- 
caps worthy  of  correction  and  that  he  could  use 
his  surgical  talents  to  help  eliminate  such  defor- 
mities. Murray's  work  helping  soldiers  in  Val- 
ley Forge  General  Hospital  and  then  at  the 
Children's  Hospital  in  Boston  served  as  a testa- 
ment to  his  deep  commitment  to  alleviating  the 
suffering  created  even  by  superficial  injuries.  In 
addition,  Murray's  curiosity  and  personal  con- 


tacts allowed  him  to  gain  an  all-encompassing 
understanding  of  the  field  of  surgery.  One  col- 
league calls  Murray  "the  paradigm  of  an  edu- 
cated surgeon",  in  that  he  enjoyed  using  other 
surgeons'  experiences  to  creatively  solve  his  own 
problems  of  procedure  or  treatment.5  In  a re- 
cent editorial  in  the  Journal  of  Plastic  and  Recon- 
structive Surgery,  he  urged  fellow  plastic  sur- 
geons to  avoid  becoming  isolated  from  the  main- 
stream, fearing  that  increased  specialization 
would  ultimately  lead  to  dissolution  of  a field 
which  has  taken  too  long  to  develop.2 

CONTEMPORARY  RELEVANCE 

Dr  Murray's  achievements  in  defining  and  el- 
evating plastics  as  a surgical  specialty  will  last 
for  all  ages.  In  particular,  his  application  of  skin 
homografting  as  a means  to  identify  tissue  com- 
patibility demonstrated  that  plastics  had  rel- 
evance in  other  surgical  fields  as  well.  Murray's 
success  in  performing  the  first  renal  transplan- 
tation won  respect  from  colleagues  in  the  surgi- 
cal community.  His  compassion  and  concern  for 
patient  care  won  loyalty  from  those  he  treated. 
He  understood  that  each  genetic  hand  was  not 
always  dealt  with  fairness  or  grace  and  that  natu- 
ral processes  such  as  aging  could  be  as  damag- 
ing as  injury  or  disease.  Where  balance  could  be 
easily  lost  by  a bullet  wound,  a genetic  imper- 
fection, or  simply  a lifetime  of  living,  Murray's 
description  of  plastic  surgery  as  "righting  this 
balance"14  brought  honor  and  integrity  to  the 
profession  as  a whole. 

REFERENCES 

1.  Rutkow  IM.  American  Surgery:  An  Illustrated  History. 
New  York:  Lippincott-Raven;  1998. 

2.  Murray  JE.  Reflections  on  plastic  surgery  at  the 
approach  of  the  millenium.  Plast  Reconstr  Surg 
2000;105:454-458. 

3.  Noe  JM.  An  interview  with  Joseph  E.  Murray  MD. 
Ann  Plast  Surg  1984;12:84-89. 

4.  Nobel  Foundation  Online:  www.nobel.se/laureates/ 
medicine-1990-l-autobio.html. 

5.  Jurkiewicz  MJ.  Nobel  Laureate:  Joseph  E.  Murray, 
clinical  surgeon,  scientist,  teacher.  Arch  Surg, 
1990;125:1423-1424. 


326  J La  State  Med  Soc  VOL  152  July  2000 


6.  Brown  JB.  Homografting  of  skin:  with  report  of 
success  in  identical  twins.  Surgery  1937;1:558-563. 

7.  Moore  FD.  Give  and  Take ; The  Development  of  Tissue 
Transplantation.  Philadelphia:  W.B.  Saunders;  1964. 

8 . Moore  FD . A Nobel  award  to  J oseph  E . Murray,  MD : 
some  historical  perspectives.  Arch  Surg 
1982;127:627-632. 

9.  Merrill  P,  Murray  JE,  Harrison  JH.  Successful  ho- 
motransplantation of  the  human  kidney  between 
identical  twins.  JAMA  1956;160:277-282. 

10.  Cannon  B.  New  honors  for  Joseph  E.  Murray,  MD 
and  Radford  C.  Tanzer,  MD.  Plast  Reconstr  Surg 
1987;80:753-754. 

1 1 . Murray  JE . Renal  transplantation:  a twenty-five  year 
experience.  Ann  Surg  1976;184:565-573. 

12.  Bynum  WF,  Porter  R (editors).  Companion  Encyclo- 
pedia of  the  History  of  Medicine,  Vol  II.  New  York: 
Routledge;  1993. 

13.  The  United  Network  for  Organ  Sharing  Online: 
www.unos.org. 

14.  Goldwyn  RM.  Joseph  E.  Murray,  MD,  Nobelist: 
some  personal  thoughts.  Plast  Reconstr  Surg 
1991;87:1110-1112. 


Ms  Rogers  is  a second-year  medical  student  at 
Tulane  University  School  of  Medicien 
in  New  Orleans,  Louisiana. 


Preventing  and  Managing 
Difficult  Patient-Physician  Relationships 

Dayton  Daberkow  II,  MD 


Virtually  every  physician  has  had  patient  encounters  that  are  frustrating  and  dissatisfying  for 
doctor  and  patient  alike.  Rather  than  label  such  patients  "difficult,"  it  may  be  more  appropri- 
ate to  call  the  patient-physician  relationship  itself  difficult.  By  identifying  possible  sources  of 
friction  in  these  encounters — the  patient  care  system  or  environment,  illness,  patient,  or  physi- 
cian— and  sharpening  your  communication  skills,  you  may  deflect  potential  unpleasantness, 
enhance  rapport,  and  ensure  greater  patient  satisfaction. 


All  physicians  care  for  patients  they  term  “dif 
ficult”,  although  definitions  of  “difficult” 
vary  from  physician  to  physician.1  Such  en- 
counters can  test  the  limits  of  our  patience  and  com- 
passion and  even  trigger  immediate  reactions  that 
are  inappropriate,  such  as  interrupting  patients,  be- 
coming curt  or  dismissive,  or  advising  them  to  seek 
solutions  for  their  problems  elsewhere.  In  hindsight, 
we  often  think  of  more  effective  ways  to  handle  these 
troubling  situations,  but  by  then  the  patients  involved 
are  gone  and  likely  now  to  view  us  as  difficult,  arro- 
gant, or  uncaring. 

Poor  communication  between  physicians  and  pa- 
tients can  create  significant  dissatisfaction  for  all 
parties  concerned,  systematically  undermining  the 


patient-physician  relationship  and  ultimately  affect- 
ing patient  care  itself.  Studies  show  that  doctors  find 
as  many  as  10%  of  all  patient  interactions  highly  frus- 
trating and  that  30%  to  40%  of  patients  were  dis- 
pleased with  their  encounters  with  physicians  in  terms 
of  the  amount  of  time  spent  and  the  opportunity  to 
explain  their  problems.2’ 3 These  problems  are  by  no 
means  new.  In  1959,  for  example,  the  editors  of  Medi- 
cal Economics  asked  300  practicing  physicians  to  list 
seven  major  complaints  about  practicing  medicine, 
and  “the  inability  to  communicate  well  enough  with 
their  patients”  ranked  prominently  among  them.4 
Similarly,  a 1984  study5  of  74  office  visits  revealed 
that  patients  were  allowed  to  complete  their  opening 
statements  of  concern  only  23%  of  the  time.  The  same 


328  J La  State  Med  Soc  VOL  152  July  2000 


study  reported  that  the  average  interval  between  pa- 
tients beginning  to  tell  their  stories  and  their  doctors 
interrupting  was  1 8 seconds.  Findings  like  these  have 
serious  implications  for  clinical  practice:  a 1998  sur- 
vey of  800  patients  revealed  that  major  factors  in 
patient  choice  of  physicians  are  the  ability  to  com- 
municate well,  to  demonstrate  a caring  attitude,  and 
to  listen  well.6  Unfortunately,  we  now  practice  in  a 
managed  care  environment  that  often  demands  higher 
patient  volumes  daily,  a scenario  that  will  likely  im- 
pede patient-physician  communication  even  further 
and  undermine  that  relationship. 

Both  the  amount  of  time  patients  spend  during 
their  office  visits  and  the  quality  of  that  time  affect 
their  level  of  satisfaction.  Shorter  office  visits  often 
fail  to  allow  patients  enough  time  to  absorb  and  un- 
derstand the  medical  findings  their  physicians  present 
them.  Gross  et  al 7 demonstrated  that  clinicians  may 
be  able  to  enhance  patients’  satisfaction  with  office 
visits  by  making  small  talk  with  them  and  increasing 
the  amount  of  time  devoted  to  providing  feedback 
on  test  results  and  physical  findings.  Even  brief  con- 
versations about  topics  unrelated  to  patient  health 
issues  may  create  greater  satisfaction  by  humanizing 
the  doctor/patient  encounter. 

Table  1 outlines  the  benefits  of  establishing  a posi- 
tive patient-physician  relationship  through  practic- 
ing good  communications  skills  and  offering  appro- 
priate feedback  to  patients;  Table  2 presents  sugges- 
tions for  increasing  patient  satisfaction  and  strength- 
ening the  patient-physician  relationship. 


Despite  our  best  efforts  to  reach  out  to  our  pa- 
tients, difficult  patient-physician  relationships  may 
still  occur.  Keller  and  White1  offer  some  suggestions 
on  how  to  approach  such  encounters.  Their  first  rec- 
ommendation is  to  recognize  and  assess  the  source 
and  nature  of  the  tension.  This  requires  that  physi- 
cians step  back  from  the  situation  and  control  their 
own  initial  responses.  Allow  patients  to  talk  and,  if 
necessary,  express  their  anger,  frustration,  or  fear, 
while  you  analyze  the  nature  of  the  encounter  and 
organize  your  thoughts.  Keller  and  White  also  rec- 
ommend that  you  assess  these  four  sources  of  diffi- 
cult relationships:  the  patient  care  system  or  envi- 
ronment, the  illness,  the  patient,  and  the  physician. 

The  patient  care  system  or  environment  may  have 
created  problems  for  patients  well  before  physician- 
patient  encounters  take  place.  For  example,  patients 
can  become  frustrated  when  they  have  trouble  park- 
ing, dealing  with  your  office  staff,  or  arranging  an 
appointment.  Remember  that  your  front  office  staff 
and  your  nurses  shape  your  patients’  initial  impres- 
sions of  you  and  your  practice.  Asking  patients  if  they 
have  encountered  such  problems  can  help  you  iden- 
tify areas  that  need  attention  in  order  to  prevent  fu- 
ture problems  for  other  patients  and  enhance  overall 
satisfaction.  Other  system-related  distractions  in  your 
relationship  with  patients  may  stem  from  the  pres- 
ence of  family  members  who  speak  for  patients  when 
their  input  is  not  warranted  or  welcome  or  from  in- 
surance plans  that  will  not  cover  certain  tests  or  treat- 
ments you  deem  necessary. 


■ •-  ...  _ ' ■ _ . ...  - • - T • . . - 

Table  1.  Benefits  of  Establishing  a Sound  Patient-Physician  Relationship 

• Increased  patient  education  and  compliance 

• Increased  patient  satisfaction  and  better  physician  report  cards  to 
insurance  plans  and  employers 

• Lower  rates  of  stressful  or  unnecessary  office  visits 

• Enhanced  sense  of  support  and  trust  on  patient’s  side 

• Diminished  depersonalization 

• Possible  reduction  in  liability-malpractice  suits 


J La  State  Med  Soc  VOL  152  July  2000  329 


Table  2.  Techniques  for  Building  a Sound  Patient-Physician  Relationship 

• Make  every  effort  to  honor  your  appointment  schedule;  when  delays  are  unavoidable, 
always  apologize  to  patients  for  the  delay. 

• Briefly  familiarize  yourself  with  the  particulars  of  each  patient’s  case  before  you 
enter  the  examining  room. 

• Knock  on  the  door  before  entering  the  examining  room  to  indicate  respect  for  patient’s 
privacy. 

• Always  greet  patients  and  if  this  is  your  first  meeting,  introduce  yourself. 

• Sit  near  your  patients  rather  than  stand  over  them;  establish  eye  contact  to  show 
them  they  have  your  undivided  attention. 

• Let  patients  speak  without  interruption  for  at  least  1 minute. 

• Ask  them  to  list  on  paper  the  problems  and  concerns  they  wish  to  address. 

• When  appropriate,  personalize  patient  encounters  by  taking  their  pulse,  holding  a 
hand,  or  lightly  touching  a shoulder.  This  is  particularly  important  at  a time  when 
health  care  settings  and  medical  technology  have  become  so  impersonal. 

• Find  something  interesting  or  distinctive  about  each  patient  and  note  this  in  your 
chart  as  a reminder  for  the  next  visit.  (How  is  Samantha  doing  in  school  since  I saw 
you  last?) 

• Empathize  with  patients  by  acknowledging  the  legitimacy  of  their  concerns  and 
feelings. 

• If  patients  are  willing,  include  family  and  friends  in  discussions. 


Clearly,  a patient’s  condition  or  illness  can  be 
another  source  of  tension.  Chronic  pain,  serious  ill- 
nesses like  cancer  or  AIDS,  and  undiagnosed  disor- 
ders, such  as  depression,  anxiety,  panic  disorder,  or 
substance  abuse,  can  dramatically  affect  patients’  abil- 
ity to  communicate  effectively  with  physicians.  Simi- 
larly, it  is  sometimes  difficult  for  both  physician  and 
patient  to  discuss  such  problems  due  to  embarrass- 
ment and  anxiety,  to  fear  that  no  treatment  or  cure  is 
available,  that  the  prognosis  is  poor,  and  such.  In  any 
case,  it  is  imperative  that  physicians  recognize  ill- 
ness and  the  associated  stress  as  a possible  barrier  to 
productive  relationships  with  their  patients  so  that 
they  don’t  blame  the  individual  patient  and  can  in- 
stead work  to  establish  trust  and  rapport. 

Patients’  personal  circumstances  and  frames  of 
reference  also  can  be  the  source  of  friction  in  the 


patient-physician  relationship.  Patients  may  be  se- 
verely depressed,  angry,  hurt,  frightened,  or  anxious, 
or  they  may  be  frustrated  because  they  have  seen 
many  doctors  for  the  same  problem  without  receiv- 
ing the  anticipated  results.  Elderly  patients  who  have 
recently  lost  loved  ones  or  are  experiencing  poor 
health  and  diminished  physical  and  mental  capabili- 
ties understandably  feel  sadness,  loneliness,  frustra- 
tion, or  helplessness.  Such  feelings  may  hinder  pa- 
tients’ willingness  to  open  up  to  or  trust  their  physi- 
cians. By  recognizing  key  patient-centered  issues  like 
these  and  understanding  their  possible  impact  on  the 
patient-physician  relationship,  we  can  be  prepared 
to  address  and  counteract  them. 

In  some  instances,  physicians  themselves  make 
relationships  with  patients  difficult.  They  may  lack 
empathy  and  leave  patients  alone  to  face  their  own 


330  J La  State  Med  Soc  VOL  152  July  2000 


conflicting  emotions  and  feelings  by  failing  to  an- 
ticipate or  address  them.  They  may  be  hurried,  high- 
pressure  interviewers  who  interrupt  patients  and  ask 
closed-ended  questions  that  don’t  permit  honest  pa- 
tient input.  For  example,  asking  “Are  you  okay  to- 
day?” may  generate  a simple  “yes”  or  “no”  response 
and  little  detail,  while  asking  “How  do  you  feel  to- 
day?” may  encourage  patients  to  engage  in  a dialogue 
with  physicians.  Other  physician-related  sources  of 
difficult  relationships  include  incomplete  patient  in- 
terviews that  focus  on  a specific  symptom  rather  than 
on  the  whole  patient  and  failure  to  secure  a complete 
patient  history.  The  latter  may  lead  to  an  incorrect 
diagnosis  with  consequences  that  include  unneces- 
sary laboratory  tests  and  needless  or  inappropriate 
referrals  to  specialists.8  Once  you’ve  assessed  the 
source  of  the  difficulty  in  the  patient-physician  rela- 
tionship, you  can  then  identify  three  main  core  prob- 
lems: misaligned  expectations,  frustrated  success,  and 
inflexibility.1 

Misaligned  expectations  occur  when  physician 
and  patient  have  differing  expectations  of  the  roles 
each  will  play  or  how  treatment  for  a problem  will 
be  initiated.  Before  they  even  see  their  physicians, 
patients  may  expect  to  undergo  a particular  proce- 
dure or  secure  a certain  prescription,  as  in  the  case  of 
the  patient  suffering  from  a cold  who  insists  he  needs 
antibiotics  or  the  young  patient  with  a minor  head- 
ache who  asks  for  a CT  scan  to  rule  out  a tumor.  The 
physician,  on  the  other  hand,  asks  the  patient  with 
the  cold  to  wait  another  week  to  see  if  the  symptoms 
resolve  and  suggests  that  the  patient  with  the  head- 
ache return  in  a week  for  further  evaluation  of  her 
symptoms.  Whenever  individual  expectations  differ, 
patients  and  physicians  may  view  each  other  as  “dif- 
ficult”. 

Frustrated  success  occurs  when  the  goals  of  ei- 
ther physician  or  patient  are  out  of  reach.  The  physi- 
cian may  define  “success”  as  effective  problem-solv- 
ing, alleviation  of  symptoms,  or  identification  of  a 
cure,  while  the  patient’s  definition  of  success  is  com- 
plete resolution  of  symptoms,  as  in  the  case  of  some- 
one who  suffers  chronic  pain  and  will  not  be  satis- 
fied unless  it  is  eliminated  altogether.  Patients  may 
become  angry  and  upset  when  a treatment  plan  is 
ineffective,  while  physicians  dealing  with  patients 
who  hinder  their  treatment  goals  may  see  such  pa- 


tients as  noncompliant  or  label  them  “difficult”. 
Mutual  dissatisfaction  results  when  both  become  frus- 
trated and  blame  each  other  for  the  lack  of  success. 

Inflexibility  results  when  physicians  and  patients 
view  their  solutions  as  the  sole  means  of  addressing 
an  illness  and  then  fail  to  compromise  on  manage- 
ment decisions.  Patients  may  be  inflexible  in  their 
wishes  to  see  only  a male  or  only  a female  physician 
or  only  a particular  specialist;  they  may  be  adamant 
about  exploring  options  for  an  illness  or  condition 
that  are  not  realistic.  Physicians  themselves  may  dem- 
onstrate inflexibility  by  not  properly  referring  a pa- 
tient to  a specialist  or  by  ignoring  a family  member’s 
request  to  explore  options  for  managing  a loved  one’s 
terminal  disease.  Such  inflexibility  creates  tension 
on  both  sides  and  can  be  one  of  the  core  problems  in 
the  relationship. 

In  addition  to  addressing  patients’  medical  prob- 
lems, physicians  must  make  a commitment  to  forg- 
ing working  relationships  with  them  and  to  enlisting 
their  help  in  working  toward  common  goals.  One 
means  to  this  end  is  to  ask  patients  open-ended  ques- 
tions that  solicit  their  input:  “What  were  you  hoping 
I would  be  able  to  do  for  you  today?”  “You’ve  been 
on  many  medications;  what  seems  to  work  best  for 
you?”  “I’ve  tried  this  approach  with  other  patients; 
what  are  your  thoughts  about  this  new  way  of  han- 
dling your  chronic  headaches?”  Show  compassion 
and  empathy  by  acknowledging  the  patient’s  present 
feelings,  whether  angry,  confused,  or  anxious:  “You 
seem  very  upset  today.  Is  there  anything  I can  do  to 
help  you?”  “This  issue  seems  to  be  difficult  for  you 
to  talk  about.  What  can  I do  to  make  it  easier?” 

Be  willing  to  compromise  with  patients  when- 
ever possible  so  that  decisions  about  their  care  are 
not  completely  one-sided  or  dominated  by  either  phy- 
sician or  patient.  For  example,  let  your  patients  know 
that  you  are  willing  to  address  all  of  their  problems 
but  that  additional  appointments  will  be  needed  to 
give  them  adequate  attention.  Assure  them  that  any 
further  tests  they  hoped  to  undergo  (ie,  CT  of  the  head, 
and  such)  may  be  appropriate  after  a period  of  “watch- 
ful waiting”.  Extend  the  system  by  asking  patients  if 
they  wish  to  include  their  families  in  the  process  and 
respecting  their  decision  on  this  issue  either  way. 
Enlisting  family  involvement  may  enhance  the  pa- 
tient-physician relationship  and  provide  support  for 


J La  State  Med  Soc  VOL  152  July  2000  331 


the  patient.  Additionally,  misunderstandings  about 
patient  care  may  be  prevented  when  discussions  in- 
clude family  members. 

These  are  all  examples  of  how  to  prevent  and 
manage  difficult  patient-physician  relationships. 
Admittedly,  some  relationships  cannot  be  salvaged, 
but  physicians  should  nonetheless  focus  on  ways  to 
save  the  majority  of  them.  Developing  strategies  that 
each  physician  finds  effective  in  managing  physician- 
patient  encounters  can  be  professionally  rewarding, 
lead  to  more  effective  patient  care,  and  ultimately 
provide  a competitive  edge  in  the  era  of  managed 
care. 


REFERENCES 

1 . White  MK,  Keller  VK.  Difficult  clinician-patient  rela- 
tionships. J Clin  Outcomes  Management  1998;5:32-36. 

2.  Schwenk  TL,  Marquez  JT,  Lefever  RD,  et  al.  Physi- 
cian and  patient  determinants  of  difficult  physician- 
patient  relationships.  J Fam  Pract  1989;28:59-63. 

3.  Cousins  N.  How  patients  appraise  physicians.  N 
Engl  J Med  1985;313:1422-1424. 

4.  Finger  AL.  Reflection  on  stuff  of  a doctor's  life:  from 
the  20's  to  the  50's.  Med  Econ  1998;75:179-181. 

5.  Beckman  HB,  Frankel  RM.  The  effect  of  physician 
behavior  on  the  collection  of  data.  Ann  Intern  Med 
1984;101:692-696. 

6.  Foley  K,  Lobdell  EB.  Factors  influencing  choice  of 
physician.  Int  Med  News  1999;32:1. 

7.  Gross  DA,  Zyzanski  SJ,  Buraski  EA,  et  al.  Patient 
satisfaction  with  time  spent  with  their  physician.  / 
Fam  Pract  1998;46:133-137. 

8.  John  C,  Schwenk  TL,  Roi  LD,  et  al.  Medical  care 
and  demographic  characteristics  of  'difficult'  pa- 
tients. J Fam  Pract  1987;24:607-610. 


Dr  Daberkow  is  Assistant  Professor, 
Section  of  Comprehensive  Medicine, 
and  the  Program  Director, 
Internal  Medicine  Residency  Training  Program, 
in  the  Department  of  Medicine, 
Louisiana  State  University  Medical  Center 
in  New  Orleans,  Louisiana. 


332  J La  State  Med  Soc  VOL  152  July  2000 


Some  dealers  waiting  list  is  two  years... 


Ours  is  more 


S430 


At  Autoflex  Leasing, 
hard  to  find  cars  are 
our  specialty. 


V V hether  it’s  a Mercedes  S500  or  S430,  the  CLK  Cabriolet 
or  all  new  Honda  S2000,  your  “hard  to  find"  car  could 
be  just  a phone  call  away.  After  all,  your  patients  don't 
like  waiting... Why  should  you? 


New  Therapies  for  Treating  Hypertension: 
What  Every  Physician  Should  Know 

Mrugeshkumar  K.  Shah,  MD;  Stephanie  Y.  Hugghins,  BS; 

Hunter  C.  Champion,  MD;  Trinity  J.  Bivalacqua,  BS 


Hypertension  is  a prevalent  health  problem  and  a major  cause  of  morbidity  and  mortality  in 
the  United  States.  It  is  one  of  the  most  important  modifiable  risk  factors  for  multiple  medical 
problems  including  coronary  artery  disease,  congestive  heart  failure,  and  end-stage  renal  dis- 
ease. There  are  many  efficacious  antihypertension  medications,  each  with  its  own  indications 
and  side  effect  profile.  Furthermore,  new  drugs  are  being  developed  rapidly.  This  article 
features  how  to  diagnose  hypertension  as  well  as  describes  pharmacological  and 
nonpharmacological  treatment  options.  The  properties,  proper  use,  and  side  effect  profile  of 
each  of  the  nine  classes  of  antihypertension  drugs  commonly  used  and  three  classes  of  medi- 
cations on  the  horizon  will  be  described.  The  purpose  of  this  manuscript  is  to  familiarize 
physicians  with  the  antihypertension  regimens  commonly  employed  and  to  introduce  drugs 
which  may  become  available  in  the  near  future. 


Hypertension  is  a concerning  health 
problem  in  the  United  States  and  one 
of  the  most  important  modifiable  risk 
factors  for  coronary  artery  disease,  stroke,  con- 
gestive heart  failure,  end-stage  renal  disease,  and 
peripheral  vascular  disease.  As  many  as  50  mil- 
lion persons  in  the  United  States  are  affected  by 
hypertension;  nearly  half  of  whom  are  un- 
treated.1 Hypertension  is  defined  as  a systolic 
blood  pressure  of  140  mm  Hg  or  greater,  a dias- 
tolic blood  pressure  of  90  mm  Hg  or  greater,  or 
the  taking  of  antihypertension  medication.2  Sev- 
eral different  forms  of  hypertension  exist.  Essen- 
tial, or  primary,  hypertension  accounts  for  ap- 
proximately 95%  of  cases;  no  cause  can  be  es- 
tablished for  this  type  of  hypertension.  Second- 


ary hypertension  refers  to  cases  in  which  a cause 
of  the  elevated  blood  pressure  can  be  identified 
such  as  estrogen  use,  renal  disease,  renal  vascu- 
lar hypertension,  primary  hyperaldosteronism 
and  Cushing's  syndrome,  pheochromocytoma, 
coarctation  of  the  aorta,  or  hypertension  associ- 
ated with  pregnancy.1  Variations  in  the  preva- 
lence of  hypertension  exist  by  gender  and  race  with 
rates  higher  in  African  Americans  and  men.34 

The  approach  to  assessing  a patient  with 
newly  diagnosed  hypertension  is  outlined  in 
Table  1.  Serial  blood  pressure  measurements 
properly  obtained  are  used  to  detect  hyperten- 
sion. The  classification  of  blood  pressure  for 
adults  is  outlined  in  Table  2.2  Repeated  measure- 
ments determine  whether  initially  elevated  values 


334  J La  State  Med  Soc  VOL  152  July  2000 


History 

•Assess  risk  factors,  specifically  inquire  about: 

Symptoms  suggesting  cardiovascular  or  cerebrovascular  disease,  such  as 
chest  pain,  headache,  visual  changes 
History  of  blood  pressure  elevation  and  prior  treatment 
Other  Medical  Problems,  such  as  diabetes,  thyroid  disease 
Social  Factors:  smoking,  alcohol  and  illicit  drug  use,  stress 
Dietary  and  Exercise  Habits 
Family  History 
Current  Medication  use 
Physical  Examination 

• More  than  two  blood  pressure  readings  (supine,  or  sitting,  and  standing  values) 

• Contralateral  arm  blood  pressure 

• Height  and  weight  measurement 

• Fundoscopic  assessment  (target  organ  damage?) 

• Neck  examination  (carotid  bruits?  thyroid  enlargement?) 

•Cardiac  examination  (S3,S4  murmurs?) 

•Abdominal  examination  (bruits,  enlarged  kidneys,  aortic  pulsations?) 

• Extremities  (peripheral  pulses,  bruits,  edema) 

Laboratory  Tests/Diagnostic  Procedures 

• Complete  blood  cell  count 

• Urinalysis 

• Basic  chemistry  with  calcium 

• Fasting  lipid  profile 

• Electrocardiogram 

Other  Tests  (depending  upon  clinical  circumstances) 

•Chest  examination 

• Echocardiogram 
•Thyroid  function  tests 
•Serum  magnesium  assay 

•Drug  screen  for  alcohol,  cocaine,  amphetamines 

• Renal  ultrasound 

• Urine  metanephrine 

Modified  from  National  Institutes  of  Health  2 


J La  State  Med  Soc  VOL  152  July  2000  335 


Table  2.  Blood  Pressure  Classification  for  Adults  (Age  = 18) 

Category 

Systolic  (mm  Hg) 

Diastolic  (mm  Hg) 

Optimal 

< 120 

and 

<80 

Normal 

< 130 

and 

< 85 

High-normal 

130-139 

or 

85-89 

Hypertension 

Stage  1 

140-159 

or 

90-99 

Stage  2 

160-179 

or 

100-109 

Stage  3 

= 180 

or 

= 110 

Modified  from  National  Institutes  of  Health  2 


persist  and  require  attention  or  have  returned  to 
normal  and  require  continued  surveillance.  The 
evaluation  of  a patient  with  hypertension  con- 
sists of  three  goals.  The  first  is  to  determine 
whether  the  patient  has  suffered  target  organ 
damage  from  hypertension.  The  presence  of  tar- 
get organ  damage  is  an  indication  for  pharma- 
cological antihypertension  therapy.  The  second 
goal  is  to  determine  whether  any  indications  of 
secondary  hypertension  are  present.  The  preva- 
lence of  secondary  hypertension  is  low;  thus, 
evaluation  of  secondary  hypertension  should  be 
based  on  signs,  symptoms,  or  laboratory  find- 
ings indicative  of  an  increased  likelihood.  Fi- 
nally, other  cardiovascular  risk  factors  should 
be  assessed.  The  probability  of  developing  fu- 
ture cardiovascular  disease  depends  on  other 
risk  factor  indicators  as  well  as  the  patient's  cur- 
rent blood  pressure.2 

Patients  with  an  average  systolic  blood  pres- 
sure of  greater  than  or  equal  to  140  mm  Hg  or 
an  average  diastolic  blood  pressure  of  greater 
than  or  equal  to  90  mm  Hg  on  at  least  three  con- 


secutive visits  should  be  started  on  drug  therapy. 
Delay  of  drug  therapy  with  close  observation 
may  be  chosen  as  an  alternative  for  patients  with 
a systolic  blood  pressure  of  140-149  or  a dias- 
tolic blood  pressure  of  90-94;  however,  the  pres- 
ence of  other  cardiovascular  disease  risk  factors 
or  target  organ  damage  are  indications  for  medi- 
cation in  these  patients.  The  goal  of  antihyper- 
tensive therapy  is  to  prevent  future  cardiovas- 
cular disease  with  minimal  side  effects.  Gener- 
ally the  target  blood  pressure  for  these  patients 
is  less  than  130/  85  mm  Hg.  The  objective  of  iden- 
tification and  treatment  of  hypertension  is  to 
decrease  the  risk  of  cardiovascular  disease  and 
associated  morbidity  and  mortality.  Antihyper- 
tensive drug  therapy  reduces  the  risk  of  end- 
stage  renal  disease,  congestive  heart  failure,  car- 
diovascular disease,  and  stroke,  as  demonstrated 
by  clinical  trials.1  It  is  important  to  know  and  to 
utilize  the  different  treatment  options;  factors 
such  as  age,  race,  sex,  and  comorbid  conditions 
must  be  considered  before  initiating  therapy. 
Treatment  methods  consist  of  nonpharmacologic 
therapies  and  pharmacologic  therapies. 


336  J La  State  Med  Soc  VOL  152  July  2000 


TREATMENT 

Nonpharmacologic 

Lifestyle  modifications  are  the  best  treatment 
option;  however,  alone  they  may  not  be  able  to 
reduce  the  blood  pressure  to  acceptable  levels. 
Before  prescribing  medications,  nonpharmaco- 
logic treatment  should  always  be  attempted  for 
at  least  6 months  unless  malignant  hypertension 
exist.  This  applies  especially  to  those  who  have 
a family  history  of  cardiovascular  complications 
or  who  have  multiple  risk  factors.  Weight  loss, 
moderate  alcohol  consumption,  and  in  some 
cases  decreasing  salt  intake  have  been  proven 
to  help.5'7  Exercise  is  also  beneficial  for  patients 
when  done  at  moderate  levels;  strenuous  exer- 
cise can  be  detrimental.8 

Pharmacologic 

Nine  major  classes  of  antihypertensive  drugs 
exist:  diuretics,  beta  blockers,  angiotensin  con- 
verting enzyme  (ACE)  inhibitors,  alpha  recep- 
tor antagonists,  calcium  channel  antagonists, 
centrally  acting  drugs,  arteriolar  dilators,  periph- 
eral sympathetic  inhibitors,  and  angiotensin  II 
receptor  antagonists.  This  article  will  highlight 
each  class  and  focus  upon  the  new  therapy  of 
the  angiotensin  II  receptor  antagonist, 
candesartan,  as  well  as  potential  future  thera- 
pies involving  endothelin  receptor  antagonists, 
renin  inhibitors,  and  vasopressin  antagonists 
(Table  3). 

Diuretics.  Diuretics  have  been  widely  used 
as  antihypertensive  medication  and  have  been 
shown  to  decrease  mortality  in  patients  with 
high  blood  pressure.  They  decrease  blood  pres- 
sure in  two  steps.  Initially  diuretics  decrease 
plasma  volume  by  inhibiting  sodium  reabsorp- 
tion. Thus,  they  increase  excretion  of  sodium  and 
water  by  the  kidney  and  thereby  decrease  car- 
diac output.  The  long-term  effect  of  diuretic 
therapy  is  reduction  in  peripheral  vascular  re- 
sistance by  an  unknown  mechanism. 

There  are  three  types  of  diuretics:  thiazide, 
loop,  and  potassium-sparing  diuretics.  Thiazide 
diuretics  increase  renal  excretion  of  sodium  and 
chloride  at  the  renal  distal  convoluted  tubule. 


leading  to  decreased  plasma  volume  and  cardiac 
output.  The  main  side  effects  are  increasing  total 
cholesterol  levels  6%  to  10%,  low  density  lipo- 
proteins (LDL)  6%  to  20%,  and  triglycerides  by 
15%  to  20%.9'10  Thiazides  are  inexpensive  and  can 
be  used  in  combination  therapy  with  ACE  inhibi- 
tors and  beta  blockers. 

The  loop  diuretics  inhibit  sodium  and  chlo- 
ride reabsorption  in  the  proximal  and  distal  tu- 
bules and  the  loop  of  Henle.  These  are  especially 
useful  in  patients  with  decreased  renal  function. 

The  potassium-sparing  diuretics  are  used  in 
combination  with  the  other  two  classes  of  diuret- 
ics to  prevent  potassium  wasting.  Spironolactone 
inhibits  the  uptake  of  aldosterone  in  the  distal 
tubule  whereas  amiloride  prevents  potassium 
excretion  by  the  distal  tubule. 

Diuretics  are  generally  more  efficacious  in 
African  Americans,  older  individuals,  obese  in- 
dividuals, and  others  with  increased  plasma  vol- 
ume and  decreased  renin  activity.  Overall,  di- 
uretics alone  can  control  blood  pressure  in  50% 
of  patients  and  can  be  used  in  combination  with 
other  agents  effectively.211  Moreover,  these 
agents  are  extremely  effective  for  patients  with 
systolic  hypertension. 

Beta-adrenergic  blockers.  Beta-adrenergic 
blockers  (beta  blockers)  decrease  heart  rate  and 
cardiac  output  by  blocking  beta  one  receptors 
in  the  heart  and  are  commonly  used  for  treating 
hypertension.  While  nonselective  beta  blockers 
such  as  propranolol  have  been  used  in  the  past, 
agents  which  have  selective  blocking  activity  at 
the  beta  one  receptor  represent  the  majority  of 
drugs  currently  used.  Although  these  beta  one 
selective  antagonists  exhibit  preference  for  the 
beta  one  receptor,  it  is  important  to  remember 
that  they  are  not  devoid  of  activity  at  the  beta 
two  binding  sites.  Nonselective  beta  blockers  are 
contraindicated  in  patients  with  severe  chronic 
obstructive  pulmonary  disease  (COPD),  el- 
evated lipids,  asthma,  or  diabetes.  The  devel- 
opment of  selective  beta  one  blockers  (cardio- 
selective)  has  opened  the  door  for  use  in  these 
populations;  however,  since  other  drugs  can  be 
given,  these  agents  are  used  with  caution.  Beta 
blockers  are  commonly  used  in  the  young,  white 


J La  State  Med  Soc  VOL  152  July  2000  337 


Table  3.  Classes  of  Anti-Hypertensive  Drugs 

Drug 

Trade  Name 

Dose  Range 

Cost  (30-day  supply)* 

Adverse  Effects 

(mg  per  day) 

Generic  ** 

Brand  ** 

Diuretics  - Thiazides 

hypokalemia,  hyperuricemia,  hyperglycemia, 

hypercholesterolemia,  hypertriglyceridemia, 
decreased  libido,  digitalis  intoxication, 
insulin  resistance,  hypercalcemia 

Hydrochlorothiazide 

Esidrix 

12.5  - 50 

$ 

$ 

Hydrodiuril 

12.5  - 50 

$ 

$ 

Microzide 

12.5  - 50 

$$ 

Chlorthalidone 

Hygroton 

25-100 

$ 

$$ 

Indapamide 

Lozol 

1.25-5 

$ 

$$ 

Metolazone 

Zaroxolyn 

5-20 

$ 

$$ 

Diuretics  - Loop 

hypokalemia,  hyperuricemia 

Furosemide 

Lasix 

20-80 

$ 

$$ 

Ethacrynic  Acid 

Edecrin 

25-100 

$-$$ 

$$  “ $$$ 

Bumetanide 

Bumex 

0.5-2 

$-$$ 

Torsemide 

Demadex 

36666 

$$  “ $$$ 

Diuretics  - Potassium  Sparing 

nausea,  hyperkalemia,  decreased  renal  function 

gynecomastia,  decreased  libido,  menstrual  disorders 

Spironolactone 

Aldactone 

25-50 

$-$$ 

$-$$ 

Triamterene 

Dyrenium 

200 

$$ 

Amiloride 

Midamor 

36666 

$ 

$$ 

Beta  Blockers 

bradyarrythmias,  masking  hypoglycemia,  fatigue,  decreased  libidio, 

bronchoconstriction,  heart  failure,  peripheral  vasoconstriction 

Propranolol 

Inderal  LA 

80  - 320 

$-$$ 

$$  “ $$$ 

Metoprolol 

Lopressor 

50  - 400 

$ 

$$  “ $$$ 

less  bronchoconstriction,  peripheral  vasoconstrction, 

Toprol  - XL 

50  - 400 

$$ 

and  masking  of  hypoglycemia 

Nadolol 

Corgard 

40  - 320 

$$$ 

Atenolol 

Tenormin 

50  - 100 

$ 

$$$ 

Labetalol 

Trandate 

Normodyne 

200  - 2400 

$$  ** 

$$  “ $$$ 

Central  Acting  Alpha  Blockers 

hemolytic  anemia,  decreased  libidio,  somnolence, 

orthostatic  hypotension,  fever,  hepatitis 

Methyldopa 

Aldomet 

500  - 3000 

$$  “ $$$ 

Clonidine 

Catapres 

0.2  - 2.4 

$ 

$$$ 

sedation,  dry  mouth,  withdrawal  hypertension,  decreased  libido 

Guanabenz 

Wytensin 

11780 

$$$ 

same  as  clonidine 

Guanfacine 

Tenex 

36528 

$$$ 

same  as  clonidine 

Reserpine 

Serpasil 

0.05  -0.1 

$$ 

depression,  peptic  ulcer,  decreased  libido,  nasal 

congestion 

Peripherally  Acting 

Adrenergic  Antagonist 

Guanethidine 

Ismelin 

18537 

$$ 

orthostatic  hypotension,  syncope,  diarrhea,  decreased  ejaculation 

Guanadrel 

Hylorel 

27668 

$$ 

same 

338  J La  State  Med  Soc  VOL  152  July  2000 


Table  3.  Classes  of  Anti-Hypertensive  Drugs,  continued. 


Alphal  Blockers 

Prazosin 

Terazosin 

Doxazosin 

Minipress 

Hytrin 

Cardura 

14642 

36545 

36541 

SS  - $$$ 
$$ 

SS  - SSS 

SS  - SSS 

orthostatic  hypotension,  syncope 
same  as  prazosin 
same  as  prazosin 

Vasodilator 

Hydralazine 

Apresoline 

40  - 300 

$ 

tachycardia,  myocardial  ischemia,  SLE  like  syndrome 

Minoxidil 

Loniten 

5-100 

$ 

tachycardia,  myocardial  ischemia,  edema, 

hypertrichosis,  pericardial  effusion 

Angiotensin  Converting 

proteinuria,  leukopenia,  dysgeusia, 

Enzyme  Inhibitors 

cough,  hyperkalemia,  angioedema.  rash 

Captopril 

Capoten 

50  - 450 

s-ss 

SSS  - ssss 

Enalapril 

Vasotec 

14732 

SSS 

Lisinopril 

Prinivil 

14885 

SSS 

Ramipril 

Altace 

2.5  - 20 

SSS 

Quinapril 

Accupril 

20-80 

SSS 

Benazepril 

Lotensin 

29495 

SS 

Fosinopril 

Monopril 

29495 

SS  - SSS 

Moexipril 

Univasc 

7.5  - 30 

SS 

Trandolapril 

Mavik 

36533 

SS  - SSS 

Calcium  Channel  Blockers 

■ Nondihydropyridines 

Diltiazem 

Cardiazem 

120-360 

SS  - SSS 

constipation,  edema 

Dilacor  XR 

180  - 540 

SS 

SSS 

Verapamil 

Calan 

240  - 360 

s$  - SSS 

SSS 

constipation,  heart  block 

Isoptin 

240  - 360 

SS 

SSS 

Verelan 

240  - 360 

SSS 

Calcium  Channel  Blockers 

■ Dihydropyridines 

Nifedipine 

Adalat  CC 

30  - 120 

s$  - SSS 

tachycardia,  headaches,  edema,  constipation 

Procardia  XL 

30  - 120 

SS  - SSS 

Isradipine 

DynaCirc 

36666 

SS  - SSS 

Felodipine 

Plendil 

36666 

SS  - SSS 

Amlodipine 

Norvasc 

2.5-10 

SSS 

Angiotension  II  Antagonist 

Losartan 

Cozaar 

50-100 

SS 

hyperkalemia 

Irbesartan 

Avapro 

75  - 300 

SSS 

Valsartan 

Diovan 

80  - 320 

SS 

Candasartan 

Atacand 

8-32 

SS  - SSS 

Telmisartan 

Micardis 

40-80 

SS 

* Cost  from  local  pharmacy  and  may  vary  based  on  location 
**$  = $ 0 - 14,  $$  = $15  - 49,  $$$  = $50  - 149,  $$$$  = $ 150  - 500 
Modified  from  National  Institutes  of  Health.  2 


J La  State  Med  Soc  VOL  152  July  2000  339 


male  population  because  this  population  gener- 
ally has  high  levels  of  renin  activity,  which  is  de- 
creased by  beta  blockers.2  911  They  are  also  good 
for  patients  with  previous  myocardial  infarctions, 
migraine,  or  angina.  Beta  blockers  and  diuretics 
are  first-line  treatments  according  to  Joint  Na- 
tional Committee  VI  (JNC  VI)  unless  the  patient's 
characteristics  require  other  drugs.2  All  beta 
blockers  tend  to  increase  triglycerides  and  depress 
high  density  lipoprotein  (HDL)  levels. 

Angiotensin  Converting  Enzyme  Inhibitors 
(ACE  inhibitors).  The  use  of  ACE  inhibitors  for 
treatment  of  mild  to  moderate  hypertension  has 
increased  in  recent  years.  ACE  inhibitors  pre- 
vent conversion  of  angiotensin  I (Ang  I)  to  an- 
giotensin II  (Ang  II)  in  the  lung  via  the  angio- 
tensin converting  enzyme;  however,  the  com- 
plete mechanism  of  action  has  not  been  eluci- 
dated. Angiotensin  II  is  a potent  vasoconstric- 
tor which  increases  total  peripheral  resistance 
thereby  increasing  blood  pressure.  It  also  regu- 
lates aldosterone  release  which  causes  the  reab- 
sorption of  sodium  and  water  in  the  distal  tu- 
bule of  the  kidney.  The  overall  effect  of  ACE  in- 
hibitors is  a decrease  in  total  peripheral  resis- 
tance by  preventing  angiotensin  II  formation  and 
through  an  indirect  mechanism  by  inhibiting 
bradykinin  metabolism  (bradykinin  is  a potent 
vasodilator).  ACE  inhibitors  are  generally  most 
effective  in  young  whites  and  account  for  ad- 
equate control  of  blood  pressure  in  40%  to  50% 
of  patients.21012  These  agents  are  useful  when 
treating  patients  with  comorbities  such  as  dia- 
betes, congestive  heart  failure,  peripheral  vas- 
cular disease,  elevated  lipids,  or  renal  insuffi- 
ciency. The  main  side  effect  (3%  to  20%)  is  cough- 
ing which  is  believed  to  be  mediated  by  brady- 
kinin. 

Calcium  channel  blockers.  Calcium  channel 
blockers  are  a relatively  new  class  of  anti- 
hypertensives. They  are  preferable  because  they 
have  few  side  effects  and  they  can  be  used  in  all 
patients,  regardless  of  age,  sex,  or  race.  Calcium 
channel  blockers  inhibit  the  flow  of  calcium  ions 
across  the  cell  membrane  in  the  heart  and  vas- 
cular smooth  muscle.  They  lower  blood  pressure 


by  decreasing  total  peripheral  resistance  through 
vasodilatation.  Verapamil  and  diltiazem  gener- 
ally decrease  heart  rate  and  contractility  of  the 
heart  whereas  the  dihydropyridine  calcium 
channel  blockers  are  peripheral  vasodilators. 
Calcium  channel  blockers  are  not  used  in  pa- 
tients with  heart  block  or  previous  myocardial 
infarctions.2  However,  they  are  effective  in  pa- 
tients with  diabetes,  COPD,  peripheral  vascu- 
lar disease,  and  renal  insufficiency.  They  are  es- 
pecially useful  in  patients  with  coronary  insuf- 
ficiency because  they  cause  vasodilatation, 
thereby  improving  coronary  circulation.1112  The 
main  side  effects  are  headache  and  edema. 

Peripheral  alpha- adrengeric  antagonists.  Al- 
pha blockers  act  at  the  postsynaptic  alpha  re- 
ceptors causing  vascular  smooth  muscle  to  re- 
lax. They  decrease  blood  pressure  by  reducing 
total  peripheral  resistance.  Alpha  blockers  are 
not  generally  used  as  monotherapy.  The  major 
side  effects  of  alpha  blockers  are  profound  hy- 
potension and  syncope;  tachyphylaxis  can  oc- 
cur with  long-term  use.11  Due  to  these  adverse 
effects,  these  drugs  are  started  slowly  and  pre- 
scribed for  nighttime  use.  They  are  beneficial  in 
male  patients  with  benign  prostatic  hypertrophy 
and  hypercholesterolemia  because  they  tend  to 
increase  HDL  and  decrease  total  cholesterol. 

Central  sympatholytic  agents.  Central 
agents  include  agonists  that  act  upon  the  alpha 
two  receptor  and  result  in  inhibition  of  dopa- 
mine and  norepinephrine  production  in  the 
brain  leading  to  a decrease  in  sympathetic  acti- 
vation in  the  body.  This  reduction  in  tone  causes 
a decrease  in  total  peripheral  resistance  which 
leads  to  a reduction  in  blood  pressure.  Methyl- 
dopa  (Aldomet)  is  used  in  pregnant  patients 
whereas  clonidine  (Catapres)  is  used  in  patients 
experiencing  alcohol  and  benzodiazepine  with- 
drawal symptoms.  Both  drugs  depress  the  cen- 
tral nervous  system  which  is  the  primary  rea- 
son for  their  discontinued  use.910 

Direct  vasodilators.  Vasodilators  decrease 
blood  pressure  by  relaxing  vascular  smooth 
muscle  thereby  causing  peripheral  vasodilation. 
This  vasodilation  leads  to  a decrease  in  total  pe- 


340  J La  State  Med  Soc  VOL  152  July  2000 


ripheral  resistance.  Vasodilators  are  generally 
used  in  combination  therapy  with  beta  blockers 
or  diuretics  because  of  the  reflex  tachycardia  and 
increase  in  contractility  associated  with  their 
use.11  Sodium  nitroprusside  is  one  of  the  most 
potent  vasodilators  used,  but  its  use  is  limited 
since  it  can  only  be  administered  intravenously. 
Oral  nitrites  such  as  isosorbide  nitrite  are  used 
extensively.  The  major  side  effect  associated  with 
hydralazine  (Apresoline)  is  a lupus-like  rash 
while  minoxidil  (Loniten)  causes  hirsutiism. 

Peripheral  acting  agents.  Peripheral  acting 
agents  are  not  extensively  used  in  hypertensive 
therapy.  Reserpine  and  guanethidine  act  at  pe- 
ripheral alpha  terminals  and  prevent  norepi- 
nephrine release.  Major  side  effects  include  pro- 
found hypotension,  sedation,  and  impotence.9'12 

Angiotensin  II  receptor  antagonists.  In  re- 
cent years  it  has  become  apparent  that  the  Re- 
nin Angiotensin  System  (RAS)  plays  an  integral 
role  in  the  development  of  arterial  hypertension. 
Moreover,  other  angiotensin-derived  metabo- 
lites have  been  shown  to  have  biological  activ- 
ity.13 The  cardiovascular  actions  of  Ang  II  and 
its  derivatives  are  mediated  via  the  AT1  recep- 
tor. The  A^  receptor  is  involved  in  blood  pres- 
sure regulation,  the  drinking  response,  and  cell 
proliferation.14  Specific  angiotensin  ATX  recep- 
tor antagonists  offer  an  alternative  approach  to 
ACE  inhibitors  of  the  RAS  system.  Ang  II  can  be 
synthesized  by  pathways  other  than  ACE.13 
Therefore,  ATX  antagonists  offer  a more  specific 
way  of  inhibiting  the  actions  of  Ang  II  and  its 
other  biologically  active  substrates.  This  ap- 
proach results  in  a more  complete  blockade  of 
the  RAS  system  as  demonstrated  by  reduced 
levels  of  plasma  aldosterone. 

The  AT1  receptor  antagonists  presently  avail- 
able in  the  United  States  are  from  a family  of 
"sartan"  compounds.  The  earliest  of  the  "sartan" 
compounds  was  losartan  (Cozaar),  followed  by 
valsartan  (Diovan),  eprosartan,  irbesartan 
(Avapro),  candesartan  (Atacand)  and  telmisartan 
(Micardis).  Losartan,  valsartan,  irbesartan  are 
presently  available  in  the  United  States  and 
candesartan  (Atacand)  was  approved  in  Octo- 


ber 1998  for  use  in  the  United  States.  ATX  recep- 
tor antagonists  do  not  cause  side  effects  such  as 
dry  cough  and  skin  rash  as  seen  with  ACE  in- 
hibitors.15 However,  early  reports  of  low  efficacy 
and  poor  antihypertensive  action  coupled  with 
high  cost  caused  AT1  receptor  blockers  to  be  used 
as  a second-line  treatment  for  hypertension. 
Most  of  the  AT2  receptor  blockers  were  reserved 
primarily  for  patients  who  develop  side  effects 
when  taking  ACE  inhibitors.  However,  the  new 
generation  of  ATX  receptor  blockers  provide  the 
efficacy  and  desirable  costs  necessary  for  first- 
line  antihypertensive  therapy.  Losartan  is  as  ef- 
fective in  reducing  blood  pressure  when  com- 
pared to  the  ACE  inhibitors  and  calcium  chan- 
nel blockers  with  no  side  effects  such  as  cough, 
which  occurs  in  patients  receiving  ACE  inhibi- 
tor therapy.16  The  metabolic  profile  in  patients 
using  AT!  receptor  blockers  as  antihypertensive 
medications  shows  similar  effects  on  lipid  and 
glucose  tolerance  as  ACE  inhibitors.  Hyperkale- 
mia, due  to  blockade  of  aldosterone  production, 
occurs  in  patients  using  ATX  receptor  blockers 
to  the  same  extent  as  with  ACE  inhibitors.16 

Candesartan  (Atacand)  is  one  of  the  newest 
selective  non-peptide  ATX  receptor  blocker  ap- 
proved for  use  in  the  United  States.  Candesartan 
is  approximately  10  times  more  potent  than 
losartan  which  was  the  most  potent  of  the  ATX 
receptor  blockers  used  for  the  treatment  of  hy- 
pertension.17 Candesartan  cilexetil  is  the  prodrug 
which  is  rapidly  converted  to  the  active  com- 
pound candesartan  during  enteric  absorption.18 
In  patients  with  essential  hypertension,  4-16  mg 
of  candesartan  significantly  reduced  blood  pres- 
sure with  maximum  effects  at  4-6  hours  and  a 
sustained  effect  observed  after  24  hours  post 
dose.19  The  usual  recommended  starting  dose  of 
candesartan  is  16  mg  once  daily  but  it  may  be 
administered  once  or  twice  daily  with  total  daily 
doses  ranging  between  8 and  32  mg.  A majority 
of  the  antihypertensive  effect  is  seen  within  2 
weeks  while  maximal  blood  pressure  reduction 
is  generally  obtained  within  4 to  6 weeks  of  treat- 
ment.19 When  candesartan  is  compared  to 
losartan  in  clinical  trials,  lower  doses  of 


J La  State  Med  Soc  VOL  152  July  2000  341 


candesartan  are  required  to  lower  blood  pressure. 
A study  on  the  antihypertensive  effects  of 
candesartan  and  losartan  by  Andersson  and 
Neldam  found  the  placebo  reductions  in  sitting 
diastolic  blood  pressure  for  active  treatment  24 
hours  post  dose  were  as  follows:  candesartan  8 
mg  once  daily,  -8.9  mm  Hg;  candesartan  16  mg 
once  daily,  -10.3  mm  Hg;  and  losartan  50  mg 
once  daily,  -6.6  mm  Hg.17  These  ratios  suggest 
that  candesartan  provides  a consistent  reduction 
in  blood  pressure  during  a 24-hour  interval, 
which  suggests  once  a day  dosing.  The  most 
common  adverse  side  effects  with  treatment  by 
both  candesartan  and  losartan  were  headache 
and  respiratory  infection.  When  candesartan  is 
compared  to  the  ACE  inhibitor  enalapril,  the 
results  of  an  8-week  treatment  period  demon- 
strated that  candesartan  (4-8  mg)  and  enalapril 
(10-20  mg)  provided  similar  blood  pressure-low- 
ering effects.20  Further  studies  have  shown  the 
therapeutic  utility  of  candesartan  when  com- 
bined with  other  agents  for  treatment  of  hyper- 
tension.2122 All  studies  to  date  demonstrate 
candesartan  is  a highly  potent,  orally  active, 
angiotensin  II  antagonist  in  humans  with  mini- 
mal adverse  effects,  long  duration  of  action  pro- 
viding a 24-hour  antagonistic  action,  and  a single 
daily  dose  for  convenient  use  by  patients. 

Telmisartan  is  a new,  potent,  orally  active, 
non-peptide  AT:  receptor  antagonist  that  is  re- 
lated to  losartan.23  Telmisartan' s pharmacologi- 
cal profile  includes  rapid  absorption  (tmax  0.5  to 
2 hours)  and  prolonged  half-life  (about  24 
hours);  together  these  aspects  may  offer  a more 
beneficial  efficacy  and  tolerablility  profile  for  the 
hypertensive  patient.  Lacourciere  and  colleagues 
demonstrated  that  telmisartan  and  amlodipine 
provided  equivalent  reductions  in  clinic  blood 
pressure,  however  telmisartan  was  tolerated 
better  by  the  patients.24  Recently,  Mallion  et  al 
exhibited  that  telmisartan  at  doses  of  40  mg  and 
80  mg  once  daily  was  effective  and  well  toler- 
ated in  the  treatment  of  mild-to-moderate  hy- 
pertension.25 These  authors  concluded  that 
telmisartan  provided  sustained  24-hour  blood 
pressure  control  and  may  offer  advantges  over 
losartan  in  terms  of  blood  pressure  reduction. 


FUTURE  THERAPY 
Renin  Inhibitors 

Renin  is  the  enzyme  responsible  for  the  conver- 
sion of  angiotensinogen  to  angiotensin  I in  the 
RAS  system.  Renin  inhibitors  have  been  shown 
to  act  as  vasodilators  and  seem  to  exert  more 
pronounced  renal  hemodynamic  effects  than 
ACE  inhibitors.26  A number  of  studies  have 
shown  that  renin  inhibitors  can  cause  a reduc- 
tion in  blood  pressure  without  side  effects  such 
as  reflex  tachycardia.  For  example,  remikiren 
exhibited  a prolonged  antihypertensive  effect  in 
patients  with  essential  hypertension,27  and  simi- 
lar dose-dependent  anti-hypertensive  effects 
have  been  demonstrated  with  FK906  and 
zankiren.28  The  major  problem  with  the  devel- 
opment of  renin  inhibitors  has  been  the 
bioavailability  of  these  compounds. 

Endothelin  Receptor  Antagonists 

The  endothelins  (ET-1,  ET-2,  and  ET-3)  are  a fam- 
ily of  related  peptides  first  discovered  in  1988. 
ET-1  is  a more  potent  vasoconstrictor  and  pres- 
sor agent  than  angiotensin  II.  The  actions  of  ET- 
1 in  humans  are  mediated  by  two  receptors,  ETA 
and  ETb,  present  in  smooth  muscle  and  endot- 
helial cells.29  In  vascular  tissue,  ETA  receptors  ex- 
pressed on  vascular  smooth  muscle  are  respon- 
sible for  vasoconstriction  and  the  ETB  receptors 
on  the  endothelium  are  linked  to  nitric  oxide  and 
prostacyclin  release  leading  to  vasodilatation. 
Selective  blockade  of  the  ETA  receptor  is  advan- 
tageous because  it  leaves  the  endothelium-de- 
pendent  vasodilation  component  of  ET-1  via  the 
ETb  receptor.  The  selective  ETA  antagonist  BQ123 
and  the  non-specific  ETA/ETB  antagonist 
TAK044  have  both  been  shown  to  cause  arterial 
vasodilation  in  healthy  volunteers.30  Kiowski 
and  colleagues  demonstrated  the  therapeutic 
utility  of  bosentan,  a non-specific  ETA/ETB  an- 
tagonist, in  reducing  mean  arterial  pressure 
without  the  reflex  neurohormonal  activation  or 
increase  in  heart  rate.31  Future  studies  concern- 
ing the  role  of  endothelins  in  the  pathogenesis  of 


342  J La  State  Med  Soc  VOL  152  July  2000 


hypertension  will  lead  to  effective  antihyperten- 
sive therapy  based  on  antagonism  or  augmenta- 
tion of  specific  functions  of  endothelins  in  the 
vasculature. 

Vasopressin  Antagonists 

Arginine  vasopressin  (AVP)  is  a potent  vasocon- 
strictor mediated  through  the  activation  of  the 
V:  receptors.  AVP  has  been  implicated  as  an  im- 
portant agent  when  volume  is  threatened,  such 
as  in  dehydration  and  hemorrhage.  The  role  of 
AVP  in  the  pathogenesis  of  hypertension  has  not 
been  fully  delineated;  however,  it  seems  to  be 
involved  when  the  sympathetic  nervous  system 
is  impaired.32  Gavras  and  colleagues  have  sug- 
gested that  AVP  has  an  important  permissive 
action  in  the  development  of  sodium-dependent 
forms  of  hypertension.33  Furthermore,  AVP  may 
be  indirectly  involved  in  hypertension  due  to  its 
role  in  volume  maintenance  or  its  interaction 
within  the  central  nervous  system.33  AVP  V:  re- 
ceptor antagonists  have  been  shown  to  have 
some  antihypertensive  effects  in  hypertensive 
patients;  however,  these  patients  were  also 
treated  with  clonidine.33  African  Americans  and 
patients  with  sympathetic  dysfunction  had  sig- 
nificant blood  pressure  lowering  effects  after 
administration  of  AVP  Vx  receptor  antagonists. 
Moreover  African-American  patients  were  found 
to  have  lower  blood  pressure  changes  after  ad- 
ministration of  an  AVP  Vx  receptor  antagonist 
when  compared  to  hypertensive  white  pa- 
tients.3435 With  the  limited  information  in  the  lit- 
erature to  date,  AVP  Vx  receptor  antagonists  seem 
most  effective  in  African-American  hyper- 
tensives. 

CONCLUSION 

If  left  untreated,  hypertension  may  progress  to 
malignant  hypertension,  a common  occurrence 
50  years  ago.  Since  that  time,  with  the  advent  of 
new  methods  for  controlling  high  blood  pres- 
sure, the  incidence  of  malignant  hypertension 
has  decreased  dramatically.  However,  even  with 
nine  classes  of  antihypertensive  agents,  hyper- 
tension is  still  a major  cause  of  morbidity  and 


mortality  in  Louisiana  and  throughout  the  coun- 
try. Moreover,  multiple  drug  regimes  are  needed 
to  control  high  blood  pressure  in  many  patients. 
Although  there  are  many  efficacious  antihyper- 
tensive agents,  further  research  is  necessary  for 
control  of  hypertensive  disorders. 

REFERENCES 

1 . Massie  BM.  Systemic  hypertension.  In:  Tierney,  LM 
Jr,  McPhee  SJ,  Papadakis  MA  (editors).  Current 
Medical  Diagnosis  and  Treatment,  37th  edition.  Stam- 
ford, Conn:  Appleton  and  Lange;  1998:429-447. 

2.  National  Institutes  of  Health.  T he  Sixth  Report  of 
the  Joint  National  Committee  on  Prevention,  Detection, 
Evaluation,  and  Treatment  of  High  Blood  Pressure  (JNC 
VI).  NIH  Publication  No.  98-4080;  November  1997. 

3.  He  J,  Whelton  PK.  Epidemiology  and  prevention 
of  hypertension.  Med  Clin  North  Am  1997;81:1077- 
1097. 

4.  Semchenko  A,  Grauer  K,  Curry  CL,  et  al.  Manage- 
ment of  uncontrolled  hypertension.  Am  Pam  Phy- 
sician Monograph  1998;2:  5. 

5.  Gordon  T,  Doyle  JT.  Alcohol  consumption  and  its 
relationship  to  smoking,  weight,  blood  pressure, 
and  blood  lipids.  Arch  Intern  Med  1986;146:262-265. 

6.  Stamler  J,  Farinaro  E,  Majonnier  LM,  et  al.  Preven- 
tion and  control  of  hypertension  by  nutritional-hy- 
gienic means.  JAMA  1980;243:1819-1823. 

7.  Rose  G,  Stamler  J.  The  Intersalt  Study:  background, 
methods  and  main  results;  Intersalt  Cooperative 
Research  Group.  J Hum  Hypertens  1989;3:283-288. 

8.  Cade  R,  Mars  D,  Wagemaker  H,  et  al.  Effect  of  aero- 
bic exercise  training  on  patients  with  systemic  ar- 
terial hypertension.  Am  J Med  1984;77:785-790. 

9.  Kaplan  NM.  Arterial  hypertension.  In:  Stein  JH 
(editor).  Internal  Medicine,  5th  edition.  Philadelphia, 
Pa:  Mosby;  1998:312-329. 

10.  Kaplan  NM.  Clinical  Hypertension,  5th  edition.  Bal- 
timore: Williams  & Wilkins;1993. 

11.  Gavras  I,  Manolis  A,  Gavras  H.  Drug  therapy  for 
hypertension.  Am  Pam  Physician  1997;55:823-1833. 

12.  Houston  MC.  New  insights  and  new  approaches 
for  the  treatment  of  essential  hypertension:  selec- 
tion of  therapy  based  on  coronary  heart  disease, 
risk  factor  analysis,  hemodynamic  profiles,  qual- 
ity of  life,  and  subsets  of  hypertension.  Am  Heart  J 
1989;117:911-951. 

13.  Moeller  I,  Allan  AM,  Chai  SY,  et  al.  Bioactive  an- 
giotensin peptides.  J Hum  Hypertens  1998;12:289- 
293. 

14.  Pratt  RE.  Angiotensin  II  and  the  control  of  cardio- 
vascular structure.  J Amer  Soc  Nephrol  1999;10:S120- 


J La  State  Med  Soc  VOL  152  July  2000  343 


S128. 

15.  Messerli  FH,  Weber  MA,  Brunner  HR.  Angiotensin 
II  receptor  inhibition  - a new  therapeutic  principle. 
Arch  Intern  Med.  1996;156:1957-1962. 

16.  Israili  ZH,  Hall  WD.  Cough  and  angioneurotic 
edema  associated  with  angiotensin  converting  en- 
zyme inhibitor  therapy:  a review  of  the  literature 
and  pathophysiology.  Ann  Intern  Med  1992;117:234- 
237. 

17.  Andersson  OK,  Neldam  S.  The  antihypertensive 
effect  and  tolerability  of  candesartan  cilexetil,  a new 
generation  angiotensin  II  antagonist,  in  compari- 
son with  losartan.  Blood  Press  1998;7:53-59. 

18.  McClellan  KJ,  Goa  KL.  Candesartan  cilexetil.  A re- 
view of  its  use  in  essential  hypertension.  Drugs 
1998;56:847-869. 

19.  Sever  P,  Holzgreve  H.  Long-term  efficacy  and  tol- 
erability of  candesartan  cilexetil  in  patients  with 
mild  to  moderate  hypertension.  J Hum  Hypertens 
1997;11:S69-S73. 

20.  Franke  H.  Antihypertensive  effects  of  candesartan 
cilexetil,  enalapril  and  placebo.  / Hum  Hypertens 
1997;11:S61-S62. 

21.  Farsang  C,  Kawecka-Jaszcz  K,  Langan  J,  et  al.  An- 
tihypertensive effects  and  tolerability  of 
candesartan  cilexetil,  amlodipine  and  their  combi- 
nation. Am  J Hypertens  1997;10:80A  (Abstract  H13). 

22.  Philip  T,  Letzel  H,  Arens  HJ.  Dose-finding  study  of 
candesartan  cilexetil  plus  hydrochlorothiazide  in 
patients  with  mild  to  moderate  hypertension.  J Hum 
Hypertens  1997;11:S67-S68. 

23.  Wienen  W,  Hauel  N,  Van  Meel  JC,  et  al.  Pharma- 
cological characterization  of  the  novel  nonpeptide 
angiotensin  II  receptor  antagonist,  BIBR  277.  Br  J 
Pharmacol  1993;110:245-253. 

24.  Lacourciere  Y,  Lenis  J,  Orchard  R,  et  al.  A compari- 
son of  the  efficacies  and  duration  of  action  of  the 
angiotensin  II  receptor  blocker  telmisartan  and 
amlodipine.  Blood  Press  Monitor  1998;3:295-302. 

25.  Mallion  JM,  Siche  JP,  Lacourciere  Y.  ABPM  com- 
parison of  the  antihypertensive  profiles  of  the  se- 
lective angiotensin  II  receptor  antagonists 
telmisartan  and  losartan  in  patients  with  mild-to- 
moderate  hypertension.  J Hum  Hypertens 
1999;13:657-664. 

26.  el  Amrani  A,  Menard  J,  Gonzales  M,  et  al.  Effects 
of  blocking  the  angiotensin  II  receptor,  converting 
enzyme,  and  renin  activity  on  the  renal  hemody- 
namics of  normotensive  guinea  pigs.  J Cardiovasc 
Pharmacol  1993;  22:231-239. 

27.  Kobrin  I,  Viskoper  R,  Laszt  A,  et  al.  Effects  of  an 
orally  active  renin  inhibitor,  RO  42-5892,  in  patients 
with  essential  hypertension.  Am  J Hypertens  1993; 
6:349-356. 


28.  Ogihara  T,  Nagano  M,  Higaski  J,  et  al.  Antihyper- 
tensive efficacy  of  FK906,  a novel  human  renin  in- 
hibitor. Clin  Ther  1993;15:539-548. 

29.  Tschudi  M,  Luscher  T.  Characterization  of  contrac- 
tile endothelin  and  angiotensin  receptors  in  human 
resistance  arteries:  evidence  for  two  endothelin  and 
one  angiotensin  receptor.  Biochem  Biophys  Res 
Commun  1994;204:685-690. 

30.  Haynes  WG,  Ferro  CJ,  Otiane  KP,  et  al.  Systemic 
endothelin  receptor  blockade  decreases  peripheral 
vascular  resistance  and  blood  pressure  in  humans. 
Circulation  1996;  93:1860-1870. 

31.  Kiowski  W,  Sutsch  G,  Hunziker  P,  et  al.  Evidence 
for  endothelin-l-mediated  vasoconstriction  in  se- 
vere chronic  heart  failure.  Lancet  1995;346:732-736. 

32.  DiPette  D,  Gavras  I,  North  W,  et  al.  Vasopressin 
responses  to  hyperosmolar  stimulus:  blood  pres- 
sure in  normal  subjects  and  in  patients  with  im- 
paired sympathetic  system.  Clin  Exp  Hypertens 
1987;6:851-861. 

33.  Gavras  I,  Gavras  H.  Role  of  vasopressin  in  hyper- 
tensive diseases.  In:  Laragh  J,  Brenner  B.  (editors). 
Hypertension,  Pathophysiology  and  Management.  New 
York:  Raven  Press;  1995:789-800. 

34.  Bakris  G,  Bursztyn  M,  Gavras  I,  et  al.  Pressor  role 
of  vasopressin  in  black  hypertensives.  Hypertension 
1991;18:378  (Abstract). 

35.  Brenner  B,  Ballerman  B,  Gunning  M,  et  al.  Diverse 
biological  actions  of  atrial  natriuretic  peptide. 
Physiol  Rev  1990;70:665-699. 


Dr  Shah  is  in  his  transitional  year, 
with  an  MS  in  Pharmacology. 

Ms  Hugghins  is  a fourth-year  medical  student, 
Department  of  Pharmacology, 
Tulane  University  School  of  Medicine, 
New  Orleans,  Louisiana. 

Dr  Champion  is  an  Internal  Medicine  Resident  at 
Johns  Hopkins  in  Baltimore,  Maryland 
and  has  a PhD  in  Pharmacology. 

Mr  Bivalacqua  is  a first-year  medical  student, 
Department  of  Pharmacology, 
Tulane  University  School  of  Medicine, 
New  Orleans,  Louisiana. 


344  J La  State  Med  Soc  VOL  152  July  2000 


Splenosis  and  the  Gynecologic  Patient: 
A Case  Report  and  Review  of  Literature 

Antonio  R.  Pizarro,  MD;  James  W.  Gallaspy,  MD;  Soheir  Nawas,  MD; 
Guillermo  Herrera,  MD;  Remi  Gomila,  MD 


A 23-year-old  woman  with  pelvic  pain  and  a preoperative  assessment  of  endometriosis  eventu- 
ally diagnosed  as  splenosis  is  presented.  Hysterectomy,  removal  of  the  ovaries  and  of  the  splenic 
pelvic  mass  resolved  her  complaint.  The  pelvic  mass  in  this  patient  was  clinically  mistaken  for 
endometriosis.  Use  of  more  specific  diagnostic  techniques  can  more  clearly  guide  therapy. 


Splenosis  is  the  growth  of  implanted 
splenic  tissue  distant  from  its  site  of  ori- 
gin as  a result  of  trauma  to  the  spleen.  Its 
diagnosis  and  clinical  significance  are  different 
from  that  of  the  accessory  spleen.  Buchbinder 
and  Lipkoff  introduced  the  term  splenosis  in 
1939. 1 The  first  reported  case  was  in  1896  by 
Albrecht,  and  since  then  approximately  90  cases 
have  been  reported.  Its  mention  in  a gynecologic 
context  remains  rare.  Splenosis  is  typically  a- 
symptomatic  and  an  incidental  finding  at  the 
time  of  gynecologic  surgery.  We  present  a case 
of  symptomatic  pelvic  splenosis  mistaken  clini- 
cally for  endometriosis. 

PATIENT  HISTORY 

A 22-year-old  woman  gravida  III  para  III  was 
followed  for  a complaint  of  2 years  of 
dyspareunia,  dysmenorrhea,  and  pelvic  pain. 


She  denied  abnormal  uterine  bleeding  or 
gastrointestinal  complaints.  Her  medical  and 
surgical  history  revealed  a splenectomy  for 
traumatic  rupture  of  the  spleen  due  to  a motor 
vehicle  accident  at  age  15.  She  had  had  three 
uncomplicated  vaginal  deliveries  and  no 
abortions.  One  year  after  the  onset  of  her  pain, 
she  underwent  laparoscopic  tubal  sterilization, 
during  which  numerous  implants  presumed  to 
be  endometriosis  were  seen  over  the  posterior 
aspect  of  the  uterus  (Figure).  No  other  such 
lesions  were  seen  in  the  pelvis  or  abdomen.  A 
diagnosis  of  severe  endometriosis  was  assigned. 

Treatment  through  medical  menopause  was 
attempted  using  a gonadotropin  releasing  hor- 
mone agonist  administered  soon  after  the  diag- 
nosis of  endometriosis  was  made.  This  was  in- 
tolerable due  to  the  associated  hot  flashes  and  a 
second  dose  was  not  given.  She  was  placed  on 


J La  State  Med  Soc  VOL  152  July  2000  345 


oral  contraceptives  and  eventually  an  NS  AID 
was  added  for  pain  control,  but  over  the  next 
year  her  symptoms  were  not  significantly  im- 
proved and  she  was  offered  hysterectomy  and 
removal  of  the  ovaries. 

FINDINGS 

Physical  examination  revealed  a healthy  woman 
with  normal  general  and  abdominopelvic  exami- 
nations. Uterosacral  ligament  nodularity  and 
pelvic  tissue  induration  were  absent.  Laboratory 
findings  and  pap  smear  were  normal. 

At  laparotomy,  examination  of  the  upper 
abdomen  and  bowel  surfaces  was  normal  except 
for  the  presence  of  adhesions  at  the  splenectomy 
site.  The  pelvic  viscerae  were  also  normal  save 
for  the  posterior  cul-de-sac  implants,  which  were 
at  the  level  of  the  lower  uterine  segment  and 
between  the  uterosacral  ligaments.  They  were 
purplish-red  and  solid  but  soft  in  consistency. 
The  largest  implant  measured  2 x 6 x 0.5  cm. 
The  implants  were  without  discrete  or  well-de- 
veloped blood  supply.  Total  hysterectomy,  bilat- 
eral salpingo-oophorectomy,  and  sharp  removal 
of  the  implants  along  their  beds  of  peritoneal 
attachment  were  performed  without  difficulty. 
Postoperative  course  and  recovery  were  un- 
eventful and  she  was  discharged  on  postopera- 
tive day  three.  She  was  administered  the  pneu- 
mococcal vaccine  prior  to  discharge,  as  she  de- 
nied having  previously  received  it. 

The  final  pathology  revealed  the  implants  to 
be  splenic  tissue  with  no  other  significant  find- 
ings. There  was  neither  a hilus  nor  significant 
vasculature. 

Eleven  months  after  surgery  she  reported 
continued  resolution  of  all  pelvic  pain. 

DISCUSSION 

Background 

Animal  studies  have  demonstrated  the  ability 
of  splenic  pulp  to  form  regenerative  implants 
on  peritoneal  surfaces.2  Unlike  in  this  case, 
splenotic  implants  can  be  very  numerous  within 
the  abdomen.  Intrathoracic  and  subcutaneous 


Figure.  Implants  of  splenosis  behind  the  uterus  at 
time  of  laparoscopic  sterilization.  Blunt  probe 
elevating  the  uterus  is  seen  at  top. 


implants  have  also  been  reported.3, 4 

The  English  literature  contains  16  cases  of 
splenosis  found  at  the  time  of  obstetric  or  gyne- 
cologic surgery.  We  present  the  seventeenth. 
Buchbinder  reported  a case  of  splenosis  diag- 
nosed incidentally  in  a woman  undergoing  ex- 
ploration for  chronic  lower  abdominal  pain.  The 
splenosis  involved  the  intestines  only.  Two  cases 
report  involvement  of  the  ovarian  stroma.5,6  A 
most  interesting  case  describes  laparoscopic 
management  of  symptomatic  pelvic  splenosis.7 
Endometriosis  has  incorrectly  been  the  diagno- 
sis in  five  cases, 812  and  was  found  to  exist  along 
with  splenosis  in  two.13,14  There  has  been  one 
reported  case  of  splenosis  identified  at  time  of 
cesarean  section.15  The  remaining  surgeries  were 
for  pelvic  pain  and  stress  incontinence,16  pelvic 
relaxation,17  abnormal  uterine  bleeding,18  and  for 
an  ovarian  cystadenoma  with  incidental 
splenosis.19  A causative  relationship  between  the 
splenosis  and  the  patients'  symptoms  was  not 
evident  in  all  of  these  cases. 

Diagnosis 

This  condition  should  be  considered  in  all 
women  undergoing  surgery  for  gynecologic 
complaints  when  there  is  a history  of  splenic 
trauma  or  rupture.  The  finding  of  a pelvic  mass 
by  physical  examination  or  ultrasound  should 
certainly  alert  the  gynecologist  to  the  possibility 
of  splenosis  in  such  women.  Selective  radionu- 


346  J La  State  Med  Soc  VOL  152  July  2000 


elide  scanning  techniques  can  be  used  to  local- 
ize splenic  tissue  and  aid  in  diagnosis.20  The 
value  of  routinely  scanning  gynecologic  patients 
at  risk  to  confirm  the  presence  of  splenic  tissue 
has  not  been  studied. 

The  differential  diagnosis  of  splenosis  in- 
cludes carcinoma,  endometriosis,  hemangi- 
omata, and  accessory  spleens.  Characteristics 
distinguishing  these  entities  may  be  difficult  to 
appreciate  at  laparoscopy,  and  biopsy  can  be 
considered.  The  potential  for  significant  bleed- 
ing caused  by  biopsy  should  be  weighed  against 
the  diagnostic  benefit. 

Management 

Surgical  management  of  splenosis  should  prob- 
ably depend  on  the  indication  for  surgery.  A 
patient  undergoing  hysterectomy  for  abnormal 
bleeding  without  pelvic  pain  may  gain  nothing 
from  removal  of  the  ectopic  splenic  tissue.  Fur- 
ther, the  risk  of  operative  bleeding  complications 
may  be  prohibitive  to  extirpation  of  splenosis, 
as  discussed  by  Auerbach.  A patient  with  pel- 
vic pain  and  a splenotic  pelvic  mass  probably 
requires  its  removal  for  symptom  relief.  The  best 
route  and  technique  for  removal  of  such  a mass 
are  unproven.  Laparoscopic  excision  can  be  at- 
tempted where  appropriate,  as  illustrated  by  the 
success  of  Higgins  and  Crain.  In  our  case,  the 
splenosis  was  easily  removed  by  essentially 
peeling  the  tissue  from  its  bed  of  attachment.  It 
is  not  known  whether  the  latter  technique  when 
compared  to  excision  increases  the  chance  of 
recurrence  or  regeneration  from  residual  micro- 
scopic tissue  at  the  bed. 

The  question  of  splenic  function  afforded  by 
splenosis  has  required  that  the  surgeon  remove 
only  the  tissue  suspected  of  causing  symptoms 
or  which  may  impede  dissection  of  structures 
involved  in  the  complaint  at  hand.  It  has  been 
suggested  that  the  protection  from  sepsis  by 
splenosis  is  probably  absent  and  that  excision 
of  the  amount  of  tissue  in  our  discussion  is  clini- 
cally insignificant.21'22  More  recent  research  has 
presented  evidence  to  the  contrary.23  The  physi- 
cian should  remind  the  woman,  when  appro- 


priate, of  the  risk  and  signs  of  infection  to  which 
the  asplenic  patient  is  susceptible  and  should 
offer  the  polyvalent  pneumococcal  vaccine  to 
those  who  have  not  yet  received  it. 

REFERENCES 

1 . Buchbinder  JH,  Lipkoff  CJ.  Splenosis:  multiple  peri- 
toneal implants  following  abdominal  injury.  Sur- 
gery 1939;6:927-933. 

2 . Kreuter  E . Experimentelle  untersuchungen  uber  die 
entstehung  der  sogenannten  nebenmilzen, 
insbesondere  nach  milzverletzungen.  Bruns  Beitr 
Klin  Chir  1920;118:76. 

3.  Cohen  EA.  Splenosis:  review  and  report  of  subcu- 
taneous splenic  implant.  Arch  Surg  1954;69:777. 

4.  Dillon  ML,  Koster  JK,  Coy  J,  et  al.  Intrathoracic 
splenosis.  South  Med  J 1977;70:112-114. 

5.  Tawfik  O,  Balarezo  F,  Weed  JC  Jr.  Splenosis:  a re- 
port of  ovarian  stromal  involvement.  Kans  Med 
1998;98:14-16. 

6.  Bullard  PD,  Markee  JE.  Ovarian  stromal 
splenosis — A case  report.  Paper  presented  at  the 
20th  Armed  Forces  Seminar  on  Obstetrics  and 
Gynecology,  Las  Vegas,  Nev,  1971. 

7.  Higgins  RV,  Crain  JL.  Laparoscopic  removal  of  pel- 
vic splenosis.  A case  report.  J Reprod  Med 
1995;40:140-142. 

8.  Matonis  LM,  Luciano  AA.  A case  of  splenosis  mas- 
querading as  endometriosis.  Am  J Ohstet  Gynecol 
1995;173(3  Pt  l):971-973. 

9.  Overton  TH.  Splenosis.  A cause  of  pelvic  pain.  Am 
J Ohstet  Gynecol  1982;43:969-970. 

10.  Watson  WJ,  Sundwall  DA,  Benson  WL.  Splenosis 
mimicking  endometriosis.  Ohstet  Gynecol  1982;59(6 
suppl):51S-53S. 

11.  Zitzer  P,  Pansky  M,  Maymon  R,  et  al.  Pelvic 
splenosis  mimicking  endometriosis,  causing  low 
abdominal  mass  and  pain.  Hum  Reprod 
1998;13:1683-1685. 

12.  Griggs  JA,  Rudoff  J,  Coddington  CC.  Mayer- 
Rokintansky-Kuster-Hauser  syndrome  with  splenosis: 
a case  report.  J Reprod  Med  1990;35:821-823. 

13.  Sinder  C,  Dochat  GR,  Wentsler  NE.  Spleno-en- 
dometriosis.  Am  J Ohstet  Gynecol  1965;92:883-884. 

14.  Maudsley  RF,  Robertson  EM.  Splenosis:  report  of  a 
case.  Ohstet  Gynecol  1965;6:486-489. 

15.  Stobie  GH.  Splenosis.  Can  Med  Assoc  J 1947;56:374- 
377. 

16.  Auerbach  RD,  Kohorn  El,  Cornelius  EA,  et  al. 
Splenosis:  a complicating  factor  in  total  abdomi- 
nal hysterectomy.  Ohstet  Gynecol  1985;65(3 
suppl):65S-68S. 


J La  State  Med  Soc  VOL  152  July  2000  347 


17.  Stovall  TG,  Ling  FW.  Splenosis:  report  of  a case  and 
review  of  the  literature.  Obstet  Gynecol  Surv 
1988;43:69-72. 

18.  Waugh  RL.  Autotransplantation  of  splenic  tissue. 
N Engl  J Med  1946;234:621-624. 

19.  Amstey  MS,  Fullerton  RE.  Splenosis  in  gynecologic 
surgery.  Obstet  Gynecol  1965;26:653-655. 

20.  Glazer  M,  Sagar  VV.  Accessory  splenic  tissue 
detection  with  Tc-99m  labeled  WBC  in  a post- 
splenectomy patient.  Clin  Nucl  Med  1995;20:283. 

21.  Livingston  CD.  Incidence  and  function  of  residual 
splenic  tissue  following  splenectomy  for  trauma 
in  adults.  Arch  Surg  1983;118:617-620. 

22.  Drew  PA,  Kiroff  GK,  Ferrante  A,  et  al.  Alterations 
in  immunoglobulin  synthesis  by  peripheral  blood 
mononuclear  cells  from  splenectomized  patients 
with  and  without  splenic  regrowth.  J Immunol 
1984;132:191-196. 

23.  Leemans  R,  Manson  W,  Snijder  JA,  et  al.  Immune 
response  capacity  after  human  splenic 
autotransplantation:  restoration  of  response  to 
individual  pneumococcal  vaccine  subtypes.  Ann 
Surg  1999;229:279-285. 


Dr  Pizarro  is  currently  a third-year  resident  physician 
in  the  Department  of  Obstetrics  and  Gynecology 
at  Louisiana  State  University  Medical  Center 
in  Shreveport , Louisiana. 

Dr  Gallaspy  was  previously  the 
staff  Physician  and  teaching  surgeon 
in  the  Department  of  Obstetrics  and  Gynecology 
at  E.A.  Conway  Hospital  in  Monroe,  Louisiana. 

DrNawas  is  currently  a staff  physician  in  the 
Department  of  Pathology  at  E.A.  Conway  Hospital 

in  Monroe,  Louisiana. 

Dr  Herrera  is  the  Chairman  of  the 
Department  of  Pathology 
at  Louisiana  State  University  Medical  Center 
in  Shreveport,  Louisiana. 

Dr  Gomila  is  the  Chairman  of  the 
Department  of  Pathology  at  E.A.  Conway  Hospital 

in  Monroe,  Louisiana. 


348  J La  State  Med  Soc  VOL  152  July  2000 


Maximizing  Medication  Adherence 
in  Low-Income  Hypertensives: 

A Pilot  Study 

Bradford  W.  Applegate,  PhD;  Steven  C.  Ames,  PhD;  Daniel  J.  Mehan  Jr,  MS; 
G.  Tipton  McKnight,  MD;  Glenn  N.  Jones,  PhD;  Phillip  J.  Brantley,  PhD 


A pilot  study  was  conducted  to  examine  the  association  between  free  medication  and 
comprehensive  care  on  blood  pressure  control  for  60  adults  with  uncontrolled  essential 
hypertension  (mean  blood  pressure  = 157/96  mm  Hg)  referred  from  a variety  of  primary  care 
clinics  at  a public  teaching  hospital.  Subjects  received  comprehensive  care,  free 
antihypertensive  medication  dispensed  in  the  clinic,  and  patient  education  regarding 
hypertension  and  medication  compliance.  Matched-pair  t-tests  revealed  average  drops  in  blood 
pressure  of  22  mm  Hg  systolic  and  13  mm  Hg  diastolic  for  the  entire  sample  from  baseline  to 
6 months  post-enrollment  (both  P's  < .001).  The  comprehensive  hypertension  management 
program  with  education  and  free  medication  was  significantly  related  to  reduced  blood 
pressure  across  the  6 months  of  the  study  period. 


Despite  significant  advances  in  the  detec- 
tion and  treatment  of  hypertension  that 
have  occurred  in  recent  years,  it  is  still 
considered  a major  health  problem.1  Approxi- 
mately 50  million  Americans  have  hypertension, 
with  annual  total  health  care  costs  for  treatment 
estimated  at  $15  billion  annually.12  Reports  from 
two  NHANES  surveys  indicate  that  the  percent- 
age of  United  States  citizens  who  are  aware  that 
they  have  the  condition  has  increased  from  51% 
to  73%.  However,  increased  awareness  has  not 
been  associated  with  increased  control.  This  is 
especially  true  in  minority  and  economically 
disadvantaged  populations,  who  have  higher 
rates  of  hypertension  as  well  as  related  end  or- 


gan damage  and  mortality.3  The  problem  of  hy- 
pertension in  minorities  and  economically  dis- 
advantaged populations  is  significant  enough  to 
warrant  special  attention  from  the  Sixth  Joint 
National  Committee  on  Prevention,  Detection, 
Evaluation,  and  Treatment  of  High  Blood  Pres- 
sure (JNC-VI).1 

Poor  adherence  to  treatment  recommenda- 
tions has  been  cited  as  a major  reason  for  inad- 
equate control  of  hypertension.4  Many  hyperten- 
sive patients  show  less  than  optimal  adherence 
to  treatment  recommendations,  including  ap- 
pointment-keeping, medication-taking,  and  life- 
style modifications  such  as  exercise  and  dietary 
improvements.5  In  particular,  poor  adherence  to 


J La  State  Med  Soc  VOL  152  July  2000  349 


medication  has  been  cited  as  one  major  reason 
for  inadequate  blood  pressure  control.4  A num- 
ber of  barriers  have  been  identified  as  predic- 
tors of  nonadherance  to  treatment,  including  det- 
rimental side  effect  profiles  of  medications,6 
complexity  of  the  treatment  regimen,7  poor  edu- 
cation,8 and  financial  barriers.910  In  low-income 
and  minority  populations,  financial  barriers  such 
as  lack  of  insurance  coverage,9  cost  of  medica- 
tions,11 poor  continuity  of  care,9  and  lack  of  ac- 
cess to  health  care  have  been  identified  as  major 
barriers  to  compliance  and  ultimately  to  blood 
pressure  control.10 

Although  researchers  have  documented  that 
a number  of  factors  might  serve  as  barriers  to 
blood  pressure  control  in  economically  disad- 
vantaged individuals  with  hypertension,  there 
are  only  very  limited  experimental  data  exam- 
ining whether  a management  program  designed 
to  remove  identified  barriers  would  be  useful 
in  enhancing  control  of  blood  pressure.  One 
study  examining  African  hypertensives  found 
that  providing  free  care  and  medication  was  as- 
sociated with  better  blood  pressure  control.12 
Other  evidence  suggesting  that  providing  free 
medication  and  care  is  associated  with  improved 
compliance  and  blood  pressure  control  comes 
from  studies  reporting  the  effects  of  disruption 
of  health  care  benefits.1314  Attempts  to  design 
management  programs  specifically  aimed  at  re- 
moving these  identified  barriers  to  adherence  in 
a low-income  population  are  absent  in  the  lit- 
erature. 

Thus,  the  current  study  sought  to  answer 
whether  providing  comprehensive  hypertension 
management  with  free  medication  would  im- 
prove blood  pressure  control  in  a sample  with 
noted  financial  barriers  such  as  poor  continuity 
of  care  and  difficulty  paying  for  medications. 
Based  on  evidence  that  the  disruption  of  health- 
care benefits  is  associated  with  decreased  blood 
pressure  control,  we  hypothesized  that  a free 
medication  program  would  be  associated  with 
enhanced  patient  compliance  with  medication 
and  improved  blood  pressure  control  within  our 
sample. 


METHODS 

Clinic  Development 

A Hypertension  Management  Program  (HMP) 
was  designed  and  implemented  to  provide  qual- 
ity medical  care  related  to  hypertension  for  low- 
income,  primary  care  patients  with  known  bar- 
riers including  poor  accessibility  and  high  cost 
of  follow-up  care,  cost  of  medications,  poor  pa- 
tient education,  and  complex  pharmacological 
regimens.  The  program  was  developed  by  an  in- 
terdisciplinary team  including  a board-certified 
physician,  a psychologist,  and  a registered  nurse. 

The  main  site  for  the  HMP  was  the  Internal 
Medicine  Clinic  of  Earl  K.  Long  Medical  Center 
(EKLMC)  in  Baton  Rouge,  Louisiana.  EKLMC 
is  a public  teaching  hospital  that  serves  economi- 
cally disadvantaged  and  uninsured  patients.  The 
Internal  Medicine  Clinic  is  housed  adjacent  to 
the  main  hospital  and  provides  primary  medi- 
cal care  to  approximately  1,300  patients/ month. 
Chart  reviews  of  patients  in  this  setting  have 
yielded  hypertension  incidence  rates  of  approxi- 
mately 60%.  Thus,  the  HMP  provided  care  to  a 
diverse  array  of  hypertensive  patients. 

All  physicians  on  the  medical  staff  at  EKLMC 
were  notified  that  a special  clinic  for  the  man- 
agement of  hypertension  was  available  and  that 
medications  would  be  furnished  to  patients  at- 
tending this  clinic.  All  patients  that  were  referred 
were  accepted  and  were  maintained  in  the  clinic 
if  their  diagnosis  of  hypertension  was  confirmed. 
One  source  that  provided  the  clinic  with  mod- 
erately severe  to  severe  hypertensive  patients 
was  the  emergency  room,  which  referred  all  pa- 
tients presenting  with  hypertensive  emergencies. 

Clinic  Structure 

The  clinic  operated  two  afternoons  per  week  in 
the  internal  medicine  clinics  of  EKLMC.  The 
clinic  was  staffed  by  three  board-certified  attend- 
ing physicians,  internal  medicine  residents,  a 
registered  pharmacist,  pre-doctoral  graduate 
students  in  clinical  psychology,  an  RN,  and  a 
trained  blood  pressure  technician. 

Subjects  enrolled  in  the  HMP  received  a 


350  J La  State  Med  Soc  VOL  152  July  2000 


multi-component  treatment  package  for  their 
hypertension  aimed  at  maximizing  compliance 
and  improving  blood  pressure  control.  Upon 
initial  visit  to  the  clinic,  a chart  review  and  physi- 
cal examination  were  conducted  and  any  neces- 
sary laboratory  work  or  procedures  were  sched- 
uled to  rule  out  secondary  causes  of  hyperten- 
sion. Patients  whose  hypertension  was  diag- 
nosed as  secondary  were  treated  but  excluded 
from  data  analysis.  Patients  with  comorbid 
medical  conditions  needing  treatment  were  ei- 
ther treated  in  the  clinic  or  arranged  appoint- 
ments through  the  appropriate  specialty  clinics 
as  necessary. 

After  careful  scrutiny  of  previous  treatment 
response,  physical  examination  results,  and  labo- 
ratory results,  patients  were  prescribed  an  anti- 
hypertensive regimen  from  a formulary  includ- 
ing the  following  classes  of  antihypertensive 
medications:  a diuretic  (furosemide),  a beta- 
blocker  (propanolol),  a calcium  channel  blocker 
(nifedipine),  an  angiotensin-converting  enzyme 
inhibitor  (verapamil),  an  alpha-blocker 
(doxazosin  mesylate),  and  a peripheral  vasodi- 
lator (minoxidil).  Prescribed  regimens  varied  by 
treatment  response,  side  effects,  and  tolerabil- 
ity by  each  patient.  Prescribing  guidelines  from 
the  JNC-VI  were  followed.  The  medications 
were  dispensed  in  the  clinic  to  the  patients  by  a 
registered  pharmacist.  The  pharmacist  provided 
informal  education  to  all  patients  regarding  the 
types  of  medications,  possible  side  effects,  and 
strategies  to  help  take  their  medications.  Pre- 
doctoral  graduate  students  in  clinical  psychol- 
ogy provided  informal  education  regarding 
medication-taking  strategies  to  help  patients  re- 
member to  take  their  medication. 

Patients  were  seen  for  biweekly  follow-up 
visits  for  the  first  4 months  of  enrollment  in  the 
clinic.  This  was  done  in  order  to  get  a stable 
baseline  of  blood  pressure,  monitor  side  effects, 
maintain  close  doctor-patient  relationships,  and 
reinforce  the  importance  of  closely  monitoring 
blood  pressure  control.  After  4 months  in  the 
clinic,  patients  whose  blood  pressure  was  un- 
der adequate  control  were  allowed  longer  time 


between  follow-up  visits  (usually  4-6  weeks). 
Patients  whose  blood  pressure  had  not  achieved 
proper  control  were  seen  more  frequently  as 
needed.  At  each  follow-up  visit,  patients  had 
their  blood  pressure  carefully  taken  by  either  a 
trained  technician  or  a registered  nurse.  An 
evaluation  was  then  conducted  by  a physician 
who  made  changes  in  the  pharmacological  regi- 
men as  necessary.  When  possible,  patients  were 
seen  by  the  same  faculty  physician,  pharmacist, 
and  house  officers  over  the  duration  of  the  clinic 
to  promote  a personal  doctor-patient  relation- 
ship. 

At  each  visit,  patients  were  asked  if  they 
failed  to  take  any  pills  prior  to  their  appointment. 
A pharmacist  performed  pill  counts  to  reinforce 
the  importance  of  taking  medications.  Reasons 
for  noncompliance  (eg,  a patient  misunderstood 
dosing  patterns)  were  explored  and  corrected 
when  necessary.  Noncompliant  patients  were 
urged  to  take  their  medications.  To  encourage 
patients  to  regularly  attend  follow-up  appoint- 
ments, patients  were  dispensed  only  enough 
medication  to  last  until  their  next  follow-up 
appointment.  Appointments  were  designed  to 
be  as  flexible  as  possible  in  order  to  accommo- 
date subjects  with  significant  schedule  restric- 
tions (eg,  inflexible  work  schedule).  Further- 
more, patients  could  be  seen  within  one  week  if 
they  desired  an  appointment  because  of  per- 
ceived or  real  side  effects  from  medications.  Sub- 
jects who  missed  scheduled  appointments  were 
phoned  the  day  of  the  missed  appointment  and 
scheduled  for  the  next  available  clinic.  Subjects 
were  called  repeatedly  in  order  to  ensure  an  ap- 
pointment for  the  next  available  clinic. 

A subset  of  participants  was  randomly  as- 
signed to  receive  education  about  hypertension 
and  techniques  to  improve  pill-taking  compli- 
ance. The  educational  sessions  were  conducted 
in  a small  group  format  in  a conference  room  in 
the  clinic.  Subjects  received  educational  litera- 
ture from  the  National  Heart,  Lung,  and  Blood 
Institute15  and  were  given  a presentation  of  the 
material  by  a trained  group  leader.  It  should  be 
noted  that  all  patients  received  substantial  edu- 


J La  State  Med  Soc  VOL  152  July  2000  351 


cation  on  an  informal  basis  throughout  their 
treatment  in  the  clinic. 

RESULTS 

Subject  Characteristics 

The  potential  subject  pool  for  this  study  con- 
sisted of  74  consecutive  hypertensive  patients 
enrolled  in  the  HMP  between  January  and  April 
1996.  Three  potential  subjects  who  were  ap- 
proached for  participation  in  our  study  were  not 
enrolled;  one  refused  to  consent  to  participate, 
another  was  ineligible  because  she  did  not  speak 
English,  and  one  patient  died  the  day  after  en- 
rollment in  our  clinic.  Eleven  subjects  who  gave 
informed  consent  were  excluded  from  analysis 
because  of  a diagnosis  of  secondary  hyperten- 
sion, leaving  60  subjects  enrolled  in  the  study. 
Subjects  tended  to  be  African  American  (77%), 


female  (70.5%),  and  to  have  had  the  diagnosis 
of  hypertension  for  9.9  + 10.7  years.  The  mean 
age  of  the  sample  was  47.1  years,  and  the  aver- 
age household  income  was  $821 /month.  Table 
1 presents  the  descriptive  statistics  for  the 
sample. 

Dropout  Analysis 

Of  the  60  enrolled  in  the  HMP,  51  (85%)  remained 
in  the  clinic  6 months  after  baseline.  Five  of  the 
dropouts  were  male,  and  four  were  African 
American.  The  main  reason  for  dropping  out  of 
the  study  was  failure  to  attend  clinic  appoint- 
ments or  inability  of  the  scheduling  nurse  to 
make  contact  with  subjects  after  missing  an  ap- 
pointment (ie,  subjects  had  either  no  phone  or 
no  steady  address).  Subjects  who  dropped  out 
of  the  study  did  not  differ  in  terms  of  baseline 
systolic  or  diastolic  blood  pressure  from  those 
who  remained  in  the  study. 


Table  1 . Demographic  Information  of  the  Sample 

Variable 

Mean 

(+/■  SD) 

% 

Age,  years 

46.7 

(+/-  9.6) 

Education,  years 

10.9 

(+/-  2.7) 

Intake  SBP,  mm  Hg 

156.8 

(+/-  23.8) 

Intake  DBP,  mm  Hg 

96.1 

(+/-  12.2) 

Family  Income,  $/month 

$830.00 

(+/-  623) 

Sex 

Female 

70 

Male 

30 

Race 

African  American 

76.7 

White 

23.3 

Marital  Status 

Single 

26.7 

Married 

40 

Separated 

5 

Divorced 

20 

Widowed 

8.3 

352  J La  State  Med  Soc  VOL  152  July  2000 


Blood  Pressure  Change  from  Baseline 
to  6 Months 

Matched-pair  t-tests  revealed  significant  drops 
in  systolic  and  diastolic  blood  pressure  from 
baseline  to  6 months  post-enrollment  (P  < .001). 
Average  systolic  blood  pressure  went  from  157 
(±  27)  mm  Hg  to  132  (±  22)  mm  Hg,  signifying 
an  average  reduction  of  25  mm  Hg.  Average 
diastolic  blood  pressure  went  from  96  (±13)  mm 
Hg  at  baseline  to  83  (±  14)  mm  Hg  at  6 months 
post-enrollment,  signifying  an  average  drop  of 
13  mm  Hg.  The  Figure  presents  the  blood  pres- 
sure of  the  sample  at  baseline  and  6 months  post- 
enrollment. A McNemar  Test  revealed  a signifi- 
cant change  in  the  number  of  controlled  subjects 
from  baseline  to  6 months  (P  < .001).  The  num- 
ber of  subjects  whose  blood  pressure  was  con- 
trolled increased  from  12%  at  baseline  to  63%  at 
6 months,  while  the  number  of  subjects  who  had 
stage  two  or  higher  blood  pressure  decreased 
from  59%  to  6%.  Table  2 presents  the  change  in 
blood  pressure  control  for  the  entire  sample  from 
baseline  to  6 months. 


ODsbp 

Udbp 


Baseline  6-Monlhs 


Figure.  Sample  Blood  Pressure  at  Baseline  and  6 
Months. 


Between  Groups  Analysis 

At  baseline,  the  average  blood  pressures  for  the 
free  medication  and  free  medication  plus  edu- 
cation groups  did  not  differ  (both  P's  > .05).  At 


6 months,  the  average  blood  pressure  for  the  free 
medication  and  free  medication  plus  education 
groups  was  132  (±  13)  / 83  (±  9)  mm  Hg  and  129 
(±  16)  / 83  (+  9)  mm  Hg,  respectively.  Indepen- 
dent sample  t-tests  examining  group  differences 
in  systolic  and  diastolic  blood  pressure  between 
the  two  experimental  conditions  at  6 months 
post-intervention  were  nonsignificant  (SBP  P = 
.56;  DBP  P = .87).  Fisher's  exact  test  was  nonsig- 
nificant for  the  number  of  subjects  with  con- 
trolled or  uncontrolled  blood  pressure  at  6 
months  (P  = .5). 


Table  2.  Blood  Pressure  Stages  From  Baseline 
to  6 Months 

Intake 

6 Months 

Controlled 

6 (12%) 

29  (63%) 

Stage  1 

15  (29%) 

19  (37%) 

Stage  II 

19  (37%) 

3 (6  %) 

Stage  III 

11  (22%) 

0 (0%) 

DISCUSSION 

The  present  study  supports  our  hypothesis  that 
providing  free  medications  and  intensive  patient 
management  to  low-income  hypertensives  is 
associated  with  improvements  in  blood  pressure 
control.  The  HMP  established  in  the  present 
study  resulted  in  a significant  drop  in  both  sys- 
tolic and  diastolic  blood  pressure  from  baseline 
to  6 months  post-enrollment  as  mean  drops  of 
25  mm  Hg  in  systolic  and  13  mm  Hg  in  diastolic 
blood  pressures  were  revealed.  In  addition,  the 
percentage  of  subjects  who  met  the  JNC-VI  cri- 
teria for  controlled  hypertension  increased  sig- 
nificantly from  12%  to  63%  over  the  same  pe- 
riod of  time.  The  addition  of  a formal  education 
group  for  half  of  the  participants  failed  to  add 
significantly  to  the  control  of  blood  pressure. 

The  dramatic  decrease  in  blood  pressure 
achieved  by  the  program  is  most  likely  attribut- 


J La  State  Med  Soc  VOL  152  July  2000  353 


able  to  reductions  in  significant  financial  barri- 
ers to  antihypertensive  treatment  compliance. 
Every  patient  in  the  HMP  had  listed  cost  of  medi- 
cations as  the  single  most  important  reason  for 
prior  nonadherence  to  treatment.  The  present 
study  reduced  the  difficulties  these  barriers  im- 
pose on  compliance  by  providing  subjects  with 
comprehensive  care  and  free  medications.  Sub- 
sequently, blood  pressure  control,  the  ultimate 
measure  of  compliance  for  hypertensives,  im- 
proved significantly.  The  high  retention  rate  of 
the  sample  (85%)  coupled  with  the  high  percent- 
age of  appointments  kept  (83%)  provide  evi- 
dence of  adherence  to  their  antihypertensive 
regimen,  especially  considering  that  the  provi- 
sion of  free  medication  was  contingent  on  ap- 
pointment keeping. 

The  results  of  this  study  are  consistent  with 
others  examining  barriers  to  care  and  blood  pres- 
sure control.  For  example,  one  recent  study  dis- 
covered that  continuity  of  care,  recent  physician 
visits,  and  the  absence  of  cost  barriers  to  the 
purchasing  of  antihypertensive  medications 
were  among  the  factors  associated  with  con- 
trolled blood  pressure  in  urban,  low-income, 
African-American  hypertensive  patients.4  The 
lack  of  a primary  care  physician  has  also  been 
shown  to  predict  uncontrolled  hypertension  in 
inner-city,  minority  hypertensives.8 

The  decrease  in  blood  pressure  obtained  by 
addressing  barriers  to  compliance  is  consistent 
with  similar  lines  of  research.  The  RAND  Health 
Insurance  Experiment  reported  that  individu- 
als receiving  free  care  (including  ambulatory  and 
hospital  care,  preventive  services,  most  dental 
services,  psychiatric  and  psychological  services, 
and  prescription  drugs)  had  significantly  lower 
blood  pressures  than  individuals  enrolled  in 
cost-sharing  medical  insurance  plans.13  Larger 
differences  were  found  for  low-income 
hypertensives  than  for  high-income  hyper- 
tensives.13 Similarly,  the  termination  of  the  Medi- 
Cal  program  in  California  (1982)  worsened  the 
health  status  of  its  former  beneficiaries.  This 
decline  in  health  status  was  evidenced  by  an 
average  increase  of  10  mm  Hg  in  diastolic  blood 


pressure  among  medically  indigent  hyperten- 
sive adults.12 

The  implications  of  this  project  are  clear.  The 
role  of  hypertension  in  poor  health  outcomes 
and  life-threatening  illness  has  been  well  estab- 
lished. Mortality  statistics  indicate  that  those 
conditions  are  responsible  for  half  of  all  deaths 
in  the  United  States.2  The  financial  burdens  that 
hypertension  and  associated  illnesses  place  on 
our  health  care  system  are  severe.  Given  that 
medication  trials  have  shown  the  ability  of  anti- 
hypertensive therapy  to  reduce  the  overall  rates 
of  cardiovascular  morbidity  and  mortality,  this 
study  suggests  that  providing  intensive  hyper- 
tension management  and  free  medication  may 
be  an  important  component  of  efforts  to  reduce 
mortality,  morbidity,  and  costs  of  hypertension- 
related  illness.  Therefore,  further  research  in- 
volving innovative  health  care  delivery  in  low- 
income  settings  is  clearly  needed.  EKLMC  has 
since  initiated  a broader  free-medication  pro- 
gram that  dispenses  free  medications  for  a num- 
ber of  chronic  medical  illnesses. 

The  recently  released  Sixth  Report  of  the 
JNC-VI  indicates  additional  implications  of  the 
current  project.1  JNC-VI  stressed  that  the  indi- 
vidual patient's  needs  must  remain  paramount 
and  that  national  guidelines  should  be  adapted 
in  local  and  individual  situations.  This  appears 
particularly  important  in  the  growing  racial  and 
ethnic  groups  that  continue  to  evidence  poorer 
control  rates  than  the  general  population.  More- 
over, the  report  echoed  previous  concerns  re- 
garding poor  adherence  to  treatment.  This  con- 
tinued therapeutic  challenge  contributes  to  the 
lack  of  adequate  control  in  more  than  two  thirds 
of  patients  with  hypertension.  The  current  study 
represents  an  important  step  in  determining  the 
effectiveness  of  particular  adherence  strategies, 
including  intensive  patient  management  and  the 
distribution  of  free  medications,  in  controlling 
hypertension  within  a low-income,  primarily 
African-American  population.  The  findings  in 
this  study  suggest  that  intensive  management 
and  free  medication  need  to  be  evaluated  on  a 
larger  and  more  controlled  scale  to  examine  the 
cost-effectiveness  of  providing  free  medication 


354  J La  State  Med  Soc  VOL  152  July  2000 


REFERENCES 


or  treatment  or  both  to  low-income  hyperten- 
sive patients. 

While  the  results  of  the  present  study  are 
encouraging  and  do  suggest  specific  methods 
for  designing  future  intervention  programs, 
some  major  limitations  of  the  study  should  be 
noted.  Most  importantly,  the  study  lacked  the 
control  groups  necessary  to  investigate  the  in- 
dependent contributions  of  free  medications  and 
patient  management  to  the  control  of  blood  pres- 
sure. Specifically,  there  were  no  groups  that  re- 
ceived usual  care  or  intensive  management  with- 
out free  medications  for  their  hypertension.  Con- 
trolled research  is  needed  to  confirm  that  pro- 
viding free  medications,  comprehensive  patient 
management,  and  patient  education  is  superior 
to  usual  care  in  low-income  patients. 

The  addition  of  patient  education  in  the  form 
of  small  classes  provided  to  half  of  the  patients 
was  not  associated  with  differences  in  blood 
pressure  control.  This  result  is  contaminated  by 
the  fact  that  patients  in  both  groups  received 
copious  amounts  of  education  on  an  informal, 
ongoing  basis.  Further  studies  need  to  examine 
the  addition  of  formal  patient  education  in  a 
controlled  fashion. 

Another  limitation  of  the  study  is  that  it 
yielded  data  on  only  the  short-term  (6  month) 
management  of  hypertension.  There  is  a possi- 
bility that  the  gains  achieved  in  this  experiment 
will  be  relatively  short-lived.  Francis  noted  the 
difficulties  of  maintaining  long-term  control  of 
blood  pressure  in  a population  of  urban  hyper- 
tensive patients  even  after  significant  barriers  to 
control  have  been  removed.8  Continuing  re- 
search must  examine  whether  free  medications 
and  intensive  patient  management  are  effective 
long-term  solutions  to  poor  hypertension  con- 
trol in  low-income  populations. 

ACKNOWLEDGEMENTS 

Funding  for  this  study  was  provided  by  a grant 
from  the  State  of  Louisiana. 

Data  from  this  study  were  presented  at  the 
18th  annual  Society  of  Behavioral  Medicine  con- 
ference, New  Orleans,  La  on  April  24,  1998. 


1 . Joint  N ational  Committee  on  Prevention,  Detection, 
Evaluation,  and  Treatment  of  High  Blood  Pressure. 
The  Sixth  Report  of  the  Joint  National  Committee 
on  Prevention,  Detection,  Evaluation,  and  Treat- 
ment of  High  Blood  Pressure.  Arch  Intern  Med 
1997;157:2413-2446. 

2.  Burt  VL,  Whelton  P,  Roccella  EJ,  et  al.  Prevalence 
of  hypertension  in  the  US  adult  population.  Hyper- 
tension 1995;25:305-313. 

3.  Moorman  PG,  Hames  CG,  Tyroler  HA.  Socioeco- 
nomic status  and  morbidity  and  mortality  in  hy- 
pertensive blacks.  In:  Saunders  E (editor).  Cardio- 
vascular Diseases  in  Blacks.  Philadelphia,  Pa:  FA 
Davis;  1991:179-192. 

4.  Monane  M,  Bohn  RL,  Gurwitz  JH,  et  al.  Compli- 
ance with  antihypertensive  therapy  among  elderly 
medicaid  enrollees:  the  roles  of  age,  gender,  and 
race.  Am  J Public  Health  1996;86:1805-1808. 

5.  Kravitz  RL,  Hays  RD,  Sherbourne  CD,  et  al.  Recall 
of  recommendations  and  adherence  to  advice 
among  patients  with  chronic  medical  conditions. 
Arch  Intern  Med  1993;153:1869-1878. 

6.  Morisky  DE,  Green  LW,  Levine  DM.  Concurrent 
and  predictive  validity  of  a self-reported  measure 
of  medication  adherence.  Med  Care  1986;24:67-74. 

7.  Eisen  SA,  Miller  DK,  Woodward  RS,  et  al.  The  ef- 
fect of  prescribed  daily  dose  frequency  on  patient 
medication  compliance.  Arch  Intern  Med 
1990;150:1881-1884. 

8.  Heurtin-Roberts  S,  Reisen  E.  Health  beliefs  and 
compliance  with  prescribed  medication  for  hyper- 
tension among  black  women  - New  Orleans,  1985- 
6.  MMWR  1990;39:701-703. 

9.  Shea  S,  Misra  D,  Ehrlich  MH,  et  al.  Predisposing 
factors  for  severe,  uncontrolled  hypertension  in  an 
inner-city  minority  population.  N Engl  J Med 
1992;327:776-781. 

10.  Shea  S,  Misra  D,  Ehrlich  MH,  et  al.  Correlates  of 
nonadherence  to  hypertension  treatment  in  an  in- 
ner-city minority  population.  Am  J Public  Health 
1992;82:1607-1612. 

11.  Shulman  NB,  Martinez  B,  Brogan  D,  et  al.  Finan- 
cial cost  as  an  obstacle  to  hypertension  therapy.  Am 
J Public  Health  1986;76:1105-1108. 

12.  Esunge  PM.  Patient  compliance  and  the  evaluation 
of  drug  trials  for  hypertension  in  rural  Africa.  Ethn 
Dis  1991;1:292-294. 

13.  Lurie  N,  Ward  NB,  Shapiro  MF,  et  al.  Termination 
from  Medi-Cal:  does  it  affect  health?  N Engl  J Med 
1984;311:480-484. 


J La  State  Med  Soc  VOL  152  July  2000  355 


14.  Keeler  EB,  Brook  RH,  Goldberg  GA,  et  al.  How  free 
care  reduced  hypertension  in  the  Health  Insurance 
Experiment.  JAMA  1985;254:1926-1931. 

15.  Moser  M.  High  Blood  Pressure  and  What  You  Can  Do 
About  It.  White  Plains:  The  Benjamin  Co;  1994. 

16.  Francis  CK.  Hypertension,  cardiac  disease,  and 
compliance  in  minority  patients.  Am  J Med 
1991;91:A29S-A36S. 


Dr  Applegate  is  now  a postdoctoral  fellow 
in  the  Department  of  Family  Medicine 
at  the  University  of  Mississippi  Medical  Center 
in  Jackson,  Mississippi. 

Dr  Ames  is  now  a postdoctoral  fellow 
in  the  Department  of  Psychiatry  & Psychology 
at  the  Mayo  Clinic  in  Rochester,  Minnesota. 

Mr  Mehan  is  now  a psychology  intern 
in  the  Department  of  Psychiatry 
at  Robert  Wood  Johnson  Medical  School 
UMDNJ,  New  Jersey. 

Dr  McKnight  is  Professor  of  Medicine  (retired) 
for  Louisiana  State  University  Health  Sciences  Center 
and  practices  medicine  in  Baton  Rouge,  Louisiana. 

Dr  Jones  is  an  associate  professor  in  the  Department  of 
Family  Medicine  with  the  LSU  Health  Sciences  Center  - 
School  of  Medicine  in  New  Orleans,  Louisiana. 

Dr  Brantley  is  a Professor  and  Chief 
of  the  Division  of  Primary  Care  Studies 
at  the  Pennington  Biomedical  Research  Center 
in  Baton  Rouge,  Louisiana. 


356 


J La  State  Med  Soc  VOL  152  July  2000 


The  Board  of  Trustees  of  the  Journal  of  the  Louisiana  State 
Medical  Society  has  faced  the  loss  of  several  members  who 
have  passed  away  this  year.  As  a result,  there  are  openings 
on  this  Board,  which  oversees  the  operation  of  the  Journal 
corporation.  Two  of  these  openings  are  to  be  filled  by 
designees  of  the  Louisiana  State  Medical  Society  Board  of 
Governors  (BOG). 

The  LSMS  Board  is  calling  for  nominations  to  these  posts 
from  among  its  members.  At  its  June  24th  meeting,  the  BOG 
determined  that  one  of  these  slots  would  be  filled  by  a medical 
student  or  resident,  while  the  other  would  come  from  its 
general  membership 

If  you  are  interested  in  being  considered  for  these 
appointments,  or  know  someone  who  would  be,  please  submit 
a letter  of  interest  and  a curriculum  vitae  to  Geraldine  Leche, 
LSMS  Executive  Assistant  (via  e-mail  at  geraldine@lsms.org; 
fax  (225)  763-6122;  or  mail  6767  Perkins  Road,  Baton  Rouge, 
Louisiana,  70808)  no  later  than  August  20,  2000. 

The  Board  of  Governors  is  expected  to  select  its 
appointments  at  its  September  20th  meeting  in  Baton  Rouge. 


J La  State  Med  Soc  VOL  152  July  2000  357 


August  2000 


1- 6  New  Orleans  Internal  Medicine  Board 

Review 

New  Orleans,  La.  Contact  (800)  648-5272. 

2- 4  26th  Annual  Psychiatry  Conference 

Aspen,  Co.  Contact  Delina  Mitchell  at  (303) 
372-9050. 

21-26  New  Orleans  Pediatrics  Board  Review 

Hyatt  Regency,  New  Orleans,  La.  Contact 
Linda  Pennix  at  (504)  568-2572.1 


September  2000 


7-10  Infectious  Diseases  Society  of  America 
38th  Annual  Meeting 

New  Orleans,  La.  Contact  IDSA  at  (800) 
424-5249. 

21-26  10th  Annual  Pediatric  Board  Review 

Bethesda,  Md.  Contact  Liane  Walters  at 
(202)  884-5993. 

28- 

Oct  1 LAPA  Primary  Care  Conference 

New  Orleans,  La.  Contact  (225)  922-4360. 


Because  this  is  no  place 
for  a doctor  to  operate. 


To  reach  your  local  off  ice, 
call  1-800-344-1899. 

www.  medical  protective,  com 


The  Medical  Protective  Company 


358  J La  State  Med  Soc  VOL  152  July  2000 


LSMS  MEETINGS 


August  2000 


1 Executive  Committee  Meeting 
5:30  pm  - Teleconference 

5 Sports  Medicine  Committee 
10:00  am 

5 Pediatric  Health  Committee 
12:00  pm 

5 Medical/Legal  Interdisciplinary  Com. 

10:00  am  - East  Jefferson  Hosp.,  N.O. 

8 Committee  on  Public  Relations 
5:30  pm  - Teleconference 

9 Committee  on  Public  Health 
5:30  pm  - Teleconference 

10  Committee  on  Maternal  & Perinatal  Health 
5:00  pm 


12  Medical  Education  Committee 
10:00  am 

18  Disaster  & EMS  Committee 
10.00  am 

21  Geriatrics  Committee 
5:00  pm  - Teleconference 

26  AMA  Delegation  Summer  Caucus 
1 1 :1 5 am  - Don’s  Seafood,  Metairie 

September  2000 

4 Labor  Day  (LSMS  office  closed) 

13  Medical  Disclosure  Panel 
1 :30  pm 

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8:00  am 


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(Unless  indicated  otherwise > all  meetinss  are  held  at  the  LSMS  Headquarters.) 


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FAMILY  PRACTICE  AND 
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Well-established  medical  group  in  Lake 
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physician  to  join  our  team  of  dedicated 
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All  inquiries  are  kept  confidential. 


360  J La  State  Med  Soc  VOL  152  July  2000 


Business  Opportunities 


LSUHSC  Seeks  Physicians 

The  Department  of  Family  Medicine  at  LSU  School  of  Medicine,  New 
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dynamic  group  of  colleagues  and  contribute  to  the  growth  of  an 
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eligible  for  a Louisiana  medical  license.  LSUHSC  is  an  EEO/AA 
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All  inquires  are  confidential.  Address  inquiries  and  CV  to  Russell  L. 
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LSU  School  of  Medicine  1542  Tulane  Ave.  New  Orleans,  LA  701 1 2; 
phone  504-568-4570;  fax  504-568-6793;  e-mail  rander@lsumc.edu. 


EMERGENCY  MEDICINE  & PRIMARY 
CARE  PHYSICIANS  NEEDED 

We  are  seeking  Board  Certified/Board 
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Positions  offer  competitive  remuneration, 
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J La  State  Med  Soc  VOL  152  July  2000  361 


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362  J La  State  Med  Soc  VOL  152  July  2000 


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Of  the  Louisiana  State  Medical  Society 


“was™ y sRyWN0 

Baltimore 


Surgical  Management  of  the  Aging  Upper  Face 
ECG  Report  of  the  Month:  The  Untamed  Heart 
Incidental  Discovery  on  Mammography  Done  for  a Palpable  Breast  Mass 
A Clinical  Report  on  Intravenous  Saline  Infusion 
The  Medical  Education  Commission  Report  at  the  Turn  of  the  New  Millennium  2000 
Does  the  Admissions  Committee  Select  Medical  Students  in  its  Own  Image? 

TB  Screening,  Referral,  and  Treatment  in  an  Inner  City  Homeless  Shelter  in  Orleans  Parish 
Kind  Strangers?  Physicians  Through  the  Eyes  of  Tennessee  Williams 


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lower  extremities  are  greatly  improved  and  can 
serve  as  an  alternative  to  invasive  conventional 
angiography  Medicare  now  provides 
coverage  and  has  approved  MRA 
as  an  appropriate  test  in  determining 
the  extent  of  peripheral  vascular 
disease  in  the  lower  extremities* 
Additionally,  MRA  has  been  shown  to  find 
occult  flow  in  blood  vessels  where  it  was  not 
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NOW  OPEN  - AVENUE  C/ MARRERO  LOCATION 


RUNON/RUNOFF 


Editor 

CONWAY  S.  MAGEE,  MD 

Chief  Executive  Officer 

DAVE  TARVER 


General  Manager 

CATHY  LEWIS 

Managing  Editor 

ANNE  SHIRLEY 

Administrative  Assistant 

MELISSA  CANTRELL 

Advertising  Sales 

ANNE  GOOCH 

BOARD  OF  TRUSTEES 
Chairman,  CONWAY  S.  MAGEE,  MD 
K.  BARTON  FARRIS,  MD 
Ex  officio,  C.  Clinton  Lewis,  MD 

EDITORIAL  BOARD 
A,  JOANNE  GATES,  MD 
RODNEY  C.  JUNG,  MD 
PATRICK  W.  PEAVY,  MD 
TRENTON  L.  JAMES  II,  MD 
JACK  P.  STRONG,  MD 
CLAY  A.  WAGGENSPACK  JR,  MD 
WINSTON  H.  WEESE,  MD 

LSMS  BOARD  OF  GOVERNORS 
C.  CLINTON  LEWIS,  MD 
DUDLEY  M.  STEWART,  MD 
KEITH  DESONIER,  MD 
LEO  L,  LOWENTRITT  JR,  MD 
K.  BARTON  FARRIS,  MD 
RUSSELL  C.  KLEIN,  MD 
WALLACE  H.  DUNLAP,  MD 
VINCENT  A.  CULOTTA  JR,  MD 
RICHARD  J.  PADDOCK,  MD 
BARRY  G.  LANDRY,  MD 
WILLIAM  T.  HALL,  MD 
JOSEPH  BUSBY  JR,  MD 
LYNN  Z.  TUCKER,  MD 
R,  MARK  WILLIAMS,  MD 
MARTIN  B.  TANNER,  MD 
MARTIN  J.  DUCOTE  JR,  MD 
MARCUS  L,  PITTMAN  III,  MD 
CHARLES  D.  BELLEAU,  MD 
JOSHUA  LOWENTRITT,  MD 
LAURA  BRESNAHAN  ROBERTS 

ESTABLISHED  1844.  Owned  and  edited  by  the 
Journal  of  the 
Louisiana  State  Medical  Society,  Inc., 
6767  Perkins  Road,  Baton  Rouge,  LA  70808; 
phone:  (225)  763-2310;  fax:  (225)  763-2332. 

e-mail:  publicaffairs@lsms.org 
Internet:  www.lsms.org 

Copyright  2000  by  the  Journal  of  the 
Louisiana  State  Medical  Society,  Inc. 

Subscription  price  is  $35  per  year  in  advance, 
postage  paid  for  the  United  States; 
$50  per  year  for  all  foreign  countries 
belonging  to  the  Postal  Union. 

Advertising:  Contact  Anne  Gooch. 
6767  Perkins  Road,  Baton  Rouge,  LA  70808; 
(225)  763-2310  or  at  (504)  895-5189,  in  New  Orleans. 

Postmaster:  Send  address  changes  to 
6767  Perkins  Road.  Baton  Rouge,  LA  70808. 

The  Journal  of  the  Louisiana  State  Medical  Society 

(ISSN  0024-6921)  is  published  monthly 
at  6767  Perkins  Road,  Louisiana  State  Medical  Society, 
Baton  Rouge,  LA  70808. 
Periodical  postage  paid  at  Baton  Rouge,  LA 
and  additional  mailing  offices. 

Articles  and  Advertisements  published  in  the  Journal 
are  for  the  interests  of  its  readers  and  do  not 
necessarily  represent  the  official  position  or 
endorsement  of  the  Journal  of  the  Louisiana 
State  Medical  Society,  Inc.  or  the 
Louisiana  State  Medical  Society. 

The  Journal  reserves  the  right  to  make  the  final 
decision  on  all  contents  and  advertisements. 


Of  the  Louisiana  State  Medical  Society 

Perry  Rigby,  MD 
Edward  Foulks,  MD 
Frank  Riddick  Jr,  MD 
Kurt  Braun,  PhD 
Robert  Daniels,  MD 
Charles  Hilton,  MD 

386 

The  Medical  Education  Commission  Report 
at  the  Turn  of  the  New  Millenium  2000 

Mollie  Wallick,  PhD 
Karl  Cambre,  MS 
Samuel  McClugage,  PhD 

393 

Does  the  Admissions  Committee  Select 
Medical  Students  in  Its  Own  Image? 

Gerald  Falchook,  BA 
Chris  Gaffga,  BA 
Sandra  Eve,  RN-C 
Juzar  Ali,  MD 

398 

Tuberculosis  Screening,  Referral,  and 
Treatment  in  an  Inner  City  Homeless 
Shelter  in  Orleans  Parish 

R.N.  McLay,  PhD 
B.  Lutz,  MD 
M.M.  Baden,  MD 
R.  Bray,  PhD 
S.  Griffies,  MD 

405 

Kind  Strangers?  Physicians  Through  the 
Eyes  of  Tennessee  Williams 

364  INFORMATION  FOR  AUTHORS 


Jorge  I.  Martinez-Lopez,  MD  367  ECG  OF  THE  MONTH 

The  Untamed  Heart 


David  Brodner,  MD 
H.  Devon  Graham  III,  MD 


370  OTOLARYNGOLOGY/HEAD  & NECK 
SURGERY  REPORT 

Surgical  Management  of  the  Aging  Upper  Face 


Sanjay  M.  Patel,  MD  377 
Jane  Clayton,  MD,  PhD 
Harold  Neitzschman,  MD 


RADIOLOGY  CASE  OF  THE  MONTH 
Incidental  Discovery  on  Mammography 
Done  for  a Palpable  Breast  Mass 


Gustavo  Colon,  MD  379  HISTORY  OF  MEDICINE 

A Clinical  Report  on  Intravenous  Saline  Infusion 
in  the  Wards  of  the  New  Orleans  Charity 
Hospital  From  June  1888  to  June  1891 

410  CALENDAR 

412  CLASSIFIED  ADVERTISING 


J La  State  Med  Soc  VOL  152  August  2000  363 


Information  for  Authors 


The  Journal  is  published  for  the  benefit  of  the  members  of  the  Louisiana  State 
Medical  Society.  Manuscripts  should  be  of  interest  to  a broad  spectrum  of 
physicians  and  designed  to  provide  practical  information  on  the  current  status 
and  the  progress  and  changes  in  the  field  of  clinical  medicine.  The  articles 
published  are  primarily  original  scientific  studies  but  may  include  societal, 
socioeconomic,  or  medicolegal  topics. 

Review  Process 

Each  submission  is  reviewed  by  the  editor  and  is  subject  to  peer  review  by  one 
of  the  editorial  consultants.  Manuscripts  are  also  subject  to  editorial  revision 
and  to  such  modification  as  to  bring  them  into  conformity  with  Journal  style. 
The  final  decision  to  accept  or  revise  falls  to  the  editor. 

Preparation  of  the  Typescript 

Allow  margins  of  at  least  1 inch  on  all  sides;  avoid  end-of-line  hyphens;  num- 
ber all  pages,  starting  with  the  title  page;  begin  each  major  part  of  the  manu- 
script on  a new  page;  double-space  all  parts  of  the  manuscript.  Submit  the 
manuscript  in  triplicate. 

Computer  Disk 

When  the  manuscript  has  been  accepted,  the  author  will  be  asked  to  submit  a 
3.5”  diskette  with  language  exactly  matching  that  of  the  accepted  version. 

Style  Conventions 

Units  of  measure.  Use  conventional  units.  If  essential,  SI  units  may  be 
added  in  parentheses  immediately  following  the  conventional  expression. 

Drug  names.  Use  the  generic  form.  If  the  proprietary  name  is  relevant  to 
the  study,  it  may  be  added  in  parentheses  immediately  following  the  first  men- 
tion of  the  generic  name.  A generic  name  is  lowercased;  a proprietary  name  is 
capitalized. 

Citing  a reference  entry.  Use  superior  arabic  numerals  placed  at  the 
logical  site  in  the  sentence;  insert  immediately  after  a word  or  mark  of  punc- 
tuation; set  close.  Cite  in  the  main  text,  in  tables,  and  in  the  legends  for 
illustrations;  do  not  cite  in  the  abstract. 

Parts  of  the  Manuscript 

Title  page.  The  title  page  should  carry  the  following  information:  (1) 
The  title  of  the  manuscript,  which  should  be  concise  but  informative.  (2)  The 
full  name  of  each  author  together  with  his  highest  academic  degree  relevant 
to  the  subject  matter  of  the  paper.  List  authors  in  the  order  of  the  magnitude 
of  their  contribution.  List  as  authors  only  those  who  have  contributed  mate- 
rially to  the  conduct  of  the  study  or  to  the  preparation  of  the  manuscript.  (3) 
The  affiliation  of  each  author  at  the  time  the  study  was  done.  (4)  Explanatory 
notes  that  give  (a)  a brief  biographical  note  for  each  author  indicating  his 
academic  appointments,  hospital  affiliations,  and  practice  location;  and  (b) 
the  name  and  address  of  the  author  to  whom  requests  for  reprints  should  be 
addressed  or  a statement  that  reprints  will  not  be  available. 

Abstract  and  Keywords.  Give  a brief  recapitulation  of  the  purpose  of 
the  paper,  the  methods  and  subjects  used,  the  results,  and  the  conclusions; 
avoid  acronyms  and  abbreviations,  do  not  cite  sources  listed  in  the  references 
section  (the  abstract  must  stand  alone);  limit  the  abstract  to  150  words. 

On  the  lower  part  of  the  same  page,  list  three  to  five  key  words  or  short 
phrases  that  will  assist  indexers.  Use  terms  from  Aledical  Subject  Headings  as 
used  in  Index Mcdicus  when  possible. 

Main  Text.  Avoid  highly  technical  expressions  and  jargon;  the  article 
should  be  easily  understood  by  the  general  readership. 

Use  subheads  freely  to  break  the  typographic  monotony,  make  the  paper 
easier  to  read,  and  fortify  the  sequence  of  the  author’s  argument.  Commonly 
used  subheads  are:  introduction  or  background,  methods  and  subjects,  re- 
sults, discussion,  and  conclusions. 

Acknowledgments.  Acknowledgments  must  be  made  for  financial  assis- 
tance (grants,  equipment,  drugs)  and  for  the  use  of  previously  published  ma- 
terial. Acknowledgment  may  be  made  for  technical  assistance  and  intellectual 
participation  in  conducting  the  study  or  preparing  the  manuscript. 

References.  Each  source  cited  in  the  main  text,  tables,  or  legends  must 
be  listed  in  the  references  section;  and,  conversely,  all  entries  in  the  references 
section  must  have  been  cited  in  the  main  text,  tables,  or  legends. 

Each  reference  entry  is  composed  of  three  elements:  ( 1 ) the  name  of  the 
author,  (2)  the  title  of  the  article  or  book,  and  (3)  the  imprint.  The  following 

364  J La  State  Med  Soc  VOL  152  August  2000 


three  examples  illustrate  the  reference  style  adopted  by  the  Journal  for  (La 
reference  to  an  article  in  a journal,  (2)  a reference  to  a book  or  monograph, 
and  (3)  a reference  to  a part  of  a larger  work. 

1.  Brush  JE  Jr,  Cannon  RO  III,  Schenke  WH,  et  al.  Angina  due  to  coro- 
nary microvascular  disease  in  hypertensive  patients  without  left  ven- 
tricular hypertrophy.  N Engl  J Med  1988;319:1302-1307. 

2.  Hajdu  SI.  Patholog}' of Soft  Tissue  Tumors.  Philadelphia,  Pa:  Lea  & 
Febiger;  1979:60-83. 

3.  Robinson  BH.  Lactic  acidemia.  In:  Scriver  CR,  Beaudet  AL,  Sly  WS, 
et  al  (editors).  The  Metabolic  Basis  of  Inherited  Disease,  6th  edition. 
New  York:  McGraw-Hill;  1989:869-888. 

Type  each  reference  entry  as  a separate  hanging  paragraph;  number  the  en- 
tries consecutively  in  the  order  cited;  do  not  list  alphabetically;  double-space 
reference  entries;  punctuate  as  shown  in  the  examples  above.  Limit  refer- 
ences to  15  unless  special  arrangements  have  been  made  with  the  editors. 

Tables.  Tables  should  be  self-explanatory  and  supplement,  not  duplicate, 
the  main  text.  All  tables  should  have  been  referred  to  in  the  main  text. 

Type  each  table  on  a separate  page;  number  tables  in  the  order  first  cited; 
provide  a title;  consult  recent  issues  of  the  Journal  for  examples. 

Legends.  Legends  identify  and  describe  tire  illustrations.  A legend  con- 
sists of  a figure  number,  a description  of  the  figure,  an  explanation  of  any 
notations  on  the  figure,  the  techniques  used,  and  an  acknowledgment  of  the 
source  if  the  figure  has  been  previously  published. 

Type  legends  together  on  a separate  page;  use  block  paragraphs.  Number 
the  figures  in  the  order  first  cited  in  the  text. 

Illustrations 

All  illustrations  should  be  referred  to  in  the  text.  An  illustration  and  its  legend 
must  stand  alone.  Illustrations  should  be  professionally  prepared.  Four-color 
illustrations  are  acceptable  at  the  author’s  expense. 

Cover  Letter 

The  manuscript  must  be  accompanied  by  a cover  letter  which  (1)  requests 
consideration  of  the  paper  for  publication  in  the  Journal ; (2)  states  that  the 
paper  has  not  been  published  previously  and  is  not  currently  being  considered 
by  another  journal;  (3)  acknowledges  any  potential  conflict  of  interest;  (4) 
states  that  the  final  manuscript  has  been  seen  by  all  of  the  authors;  and  (5) 
designates  one  of  the  authors  as  corresponding  author  and  lists  his  full  mailing 
address,  telephone  number,  fax  number,  and  e-mail  address. 

Permissions 

Written  permission  must  be  obtained  from  ( 1 ) any  individual  who  is  recog- 
nizable in  text  or  illustration,  (2)  the  copyright  owner  of  any  previously  pub- 
lished matter  (text,  table,  or  figure)  which  is  to  be  incorporated  in  the  manu- 
script, and  (3)  any  individual  mentioned  in  the  acknowledgments. 

Copyright  Transfer 

Authors  will  be  asked  to  sign  a form  transferring  to  the  Journal  copyright 
ownership  of  any  article  accepted  for  publication.  Such  articles  may  not  be 
published  elsewhere,  in  whole  or  in  part,  without  written  permission  from  the 
editors. 

Galley  Proofs 

Galley  proofs  will  be  mailed  to  the  corresponding  author  for  review. 

Editorial  Assistance 

An  expanded  version  of  Information  for  Authors  is  published  in  the  January 
and  July  issues.  For  help  in  preparing  your  manuscript  or  for  questions  about 
the  editorial  process,  write  the  Editor  or  the  Managing  Editor  as  below.  Or, 
contact  the  Editor,  Dr  Magee,  at  (337)  439-8450,  FAX  (337)  439-7576;  e- 
mail:  comvaystonemagee@compuserve.com;  or  the  Managing  Editor,  Anne 
Shirley  at  (225)  763-8500,  FAX  (225)  7 63-2332,  or  e-mail: 
publicaffairs@lsms.org. 

Submission  of  the  Manuscript 

Submit  the  manuscript  (in  triplicate),  the  illustrations  (two  copies  each),  the 
required  permissions,  and  a cover  letter  to: 

Editor,  Journal  of  the  Louisiana  State  Medical  Society 
6767  Perkins  Rd. 

Baton  Rouge,  LA  70808 


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ECG  of  the  Month 


The  Untamed  Heart 

Jorge  I.  Martinez-Lopez,  MD 


The  12-lead  ECG  and  rhythm  strip  shown  below  belongs  to  a 43-year-old  woman.  It  was 
recorded  in  the  ER,  where  she  presented  complaining  of  palpitations.  She  had  been 
hospitalized  numerous  times  in  the  previous  7 years  for  the  same  complaint.  She  was  not 


What  is  your  diagnosis? 
Elucidation  begins  on  page  368. 


J La  State  Med  Soc  VOL  152  August  2000  367 


ECG  of  the  Month 
Presentation  is  on  page  367. 

DIAGNOSIS  - Supraventricular  tachycardia , type? 

The  tracing  shows  a regular  tachycardiac 
rhythm,  at  135  times  a minute,  with  narrow  QRS 
complexes.  The  narrowness  of  the  QRS  com- 
plexes indicates  that  intraventricular  conduction 
is  normal  and  that  the  electrical  impulses  re- 
sponsible for  biventricular  depolarization  origi- 
nate in  the  supraventricular  areas  of  the  heart. 
For  these  reasons,  it  may  be  appropriate  to  clas- 
sify the  arrhythmia  as  supraventricular  tachycar- 
dia (SVT).  However,  such  categorization  is  more 
descriptive  than  it  is  a final  or  precise  ECG  di- 
agnosis. SVT  includes  multiple  and  distinct  ar- 
rhythmia mechanisms;  some  SVTs  require  the 
AV  node  and  ventricles  for  their  initiation  and 
sustenance,  while  others  do  not. 

Because  the  SVT  shown  here  is  regular , ex- 
clusion of  atrial  flutter  with  variable  AV  ratios, 
atrial  fibrillation,  and  multifocal  atrial  tachycar- 
dia from  the  list  of  potential  diagnoses  is  pos- 
sible. The  remaining  diagnostic  possibilities  in- 
clude inappropriate  sinus  tachycardia,  atrial 
tachycardia,  atrial  flutter  with  2:1  AV  conduc- 
tion ratios,  and  also  AV  junctional  reentrant  ta- 
chycardia and  orthodromic  AV  reentrant  tachy- 
cardia using  an  accessory  pathway. 

The  key  to  differentiate  these  different  SVTs 
from  each  other  is  the  search  for  atrial  electrical 
activity,  in  the  form  of  P waves  or  atrial  flutter 
waves,  and  to  determine  the  relationship  of 
atrial  electrical  activity  to  the  QRS  complexes. 
Examination  of  the  tracing  clearly  shows  in- 
verted P waves  in  leads  II,  III,  AVF,  and  in  pre- 
cordial leads  V2  through  V6;  they  keep  a con- 
stant 1:1  AV  relationship  with  the  QRS  com- 
plexes. These  findings  eliminate  inappropriate 
sinus  tachycardia  and  atrial  flutter  from  further 
consideration. 

Another  helpful  clue  in  the  differential  di- 
agnosis of  SVT  is  the  location  of  the  inverted  P 
wave  in  relation  to  the  R-R  interval.  The  ques- 


tion is:  Is  the  R-P  interval  shorter  or  longer  than 
the  P-R  interval?  Here,  the  tracing  shows  that 
the  R-P  interval  is  longer  than  the  P-R  interval, 
and  that  the  R-P  interval  remains  constant 
throughout  the  tracing.  Finding  the  R-P  interval 
to  be  longer  than  the  P-R  interval  further  nar- 
rows down  the  potential  causes  of  SVT  to  the 
following:  atrial  tachycardia — both  automatic 
and  reentrant — and  the  uncommon  forms  of  AV 
junctional  reentrant  tachycardia  (fast-slow  and 
slow-slow)  or  orthodromic  AV  reentrant  tachy- 
cardia involving  a slowly  conducting  retrograde 
accessory  pathway. 

Non-invasive  efforts  to  define  the  mecha- 
nism responsible  for  the  "untamed  heart"  in- 
cluded the  intravenous  administration  of  either 
adenosine  or  diltiazem.  Responses  of  the  SVT 
to  the  administration  of  these  agents  varied:  of- 
ten SVT  was  abruptly  terminated,  but  at  other 
times  the  tachycardia  remained  unabated.  Nei- 
ther of  these  agents  induced  AV  block  without 
interruption  of  the  SVT.  Together,  these  re- 
sponses are  against  the  diagnosis  of  atrial  tachy- 
cardia and  enhance  the  likelihood  of  an  SVT 
which  requires  AV  nodal  and  ventricular  par- 
ticipation for  its  initiation  and  sustenance. 

Although  the  specific  nature  of  the  SVT  has 
not  been  conclusively  demonstrated  in  this  pa- 
tient, additional  observations  made  at  the  onset 
and  the  conclusion  of  the  arrhythmia  strongly 
support  the  notion  that  the  SVT  represents  an 
uncommon  form  of  either  AV  junctional  or  AV 
reentrant  tachycardia.  First , the  arrhythmia  is 
triggered  by  a premature  atrial  impulse,  which 
displays  an  inverted  P wave  that  is  identical  to 
those  which  follow  during  the  SVT.  Second , spon- 
taneous cessation  of  the  SVT  is  characterized  by 
a non-conducted,  inverted  P wave — a QRS  does 
not  follow  it.  After  the  pause  caused  by  the  non- 
conducted  P wave,  sinus  rhythm  is  restored  for 
variable  periods  of  time.  Third , at  no  time — af- 
ter sinus  rhythm  is  restored — has  a ventricular 
preexcitation  (WPW)  pattern  been  recorded. 
This  fact,  however,  does  not  eliminate  the  pos- 
sibility that  a "concealed"  accessory  pathway  is 
present;  one  which  would  only  allow  conduc- 


368  J La  State  Med  Soc  VOL  152  August  2000 


tion  to  proceed  retrogradely  from  ventricle  to 
atrium. 

Because  of  the  frequent,  sustained  recur- 
rences of  SVT,  even  when  the  patient  is  in  the 
hospital  under  medical  care,  invasive 
electrophysiologic  studies  and  possible 
radiofrequency  ablation  therapy  were  recom- 
mended, in  an  attempt  to  harness  the  "untamed 
heart".  Three  times,  the  patient  consented  to 
have  these  procedures  done  and  each  time,  she 
failed  to  show  up.  Pharmacologic  therapy  is 
"useless"  for  this  patient  because  she  is  not  com- 
pliant with  treatment  or  follow-up. 

No  definite  evidence  of  structural  heart  dis- 
ease has  been  uncovered  in  this  patient.  A re- 
cent echocardiogram,  however,  showed  isolated 
left  atrial  enlargement.  This  acquired  abnormal- 
ity has  been  attributed  to  the  repetitive,  sustained 
episodes  of  SVT,  which  may  cause  a tachycar- 
dia-induced atrial  "myopathy".  In  some  patients 
with  "untamed"  SVT,  tachycardia-induced  car- 
diomyopathy may  eventually  lead  to  left  ven- 
tricular dysfunction  and  cardiac  failure. 


Dr  Martinez-Lopez  is  a specialist  in  cardiovascular 
diseases  affiliated  ivith  the  Cardiology  Service,  Department 
of  Medicine,  Texas  Tech  University  Health  Sciences  Center 
and  Thomason  General  Hospital  in  El  Paso,  Texas. 


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L A W • F I R M 

Devoted  to  the  Representation  and  Counseling 
of  the  Health  Care  Industry 

The  Gachassin  Law  Firm  provides  quality,  cost- 
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health  care  industry.  Our  attorneys  are  experienced 
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management  organizations,  Medicare  and 
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and  Stark  compliance,  regulatory  and  legislative 
issues,  medical  malpractice  defense  and  risk 
management. 

Nicholas  Gachassin,  Jr.  Nicholas  Gachassin,  III 

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Telephone:  (337)  235-4576 * Fax:  (337)  235-5003 

E-Mail:  gh@gachassin.com 
www.gachassin.com 


J La  State  Med  Soc  VOL  152  August  2000  369 


Otolaryngology/ 

a i _ . 


Surgical  Management 
of  the  Aging  Upper  Face 

David  C.  Brodner,  MD  and  H.  Devon  Graham  III,  MD 


Creating  a more  youthful  appearance  of  the  aging  upper  face  requires  a treatment  plan 
which  is  tailored  to  address  the  patient's  individual  needs.  The  process  begins  with  a 
comprehensive  knowledge  of  anatomy  and  the  physical  effects  of  aging,  involves  discussion 
and  understanding  of  aesthetic  ideals,  and  culminates  in  the  selection  and  performance  of 
the  appropriate  procedure. 


Cosmetic  surgery  aims  to  create  a more 
youthful  appearance  by  repositioning 
soft  tissues  in  order  to  correct  the  effects 
of  aging.  The  optimal  treatment  plan  is  tailored 
to  address  the  patient's  unique  physical  at- 
tributes while  also  complying  with  personal 
aesthetic  ideals.  To  achieve  this  goal,  the  sur- 
geon must  possess  a comprehensive  knowledge 
of  anatomy,  the  physical  effects  of  aging,  and 
the  variety  of  available  surgical  approaches. 

ANATOMY 

The  complex  actions  of  the  facial  musculature 
allow  expression  of  many  emotions.  The  mi- 
metic muscles  of  the  upper  one  third  of  the  face 


include  the  frontalis,  procerus,  depressor 
supercilii,  corrugator  supercilii,  and  orbital  por- 
tion of  the  orbicularis  oculi. 

The  frontalis  muscle  is  the  sole  elevator  of 
the  forehead.  Its  paired  muscle  bellies  are  ori- 
ented in  a vertical  fashion  at  a slight  lateral  to 
medial  angle.  The  frontalis  has  no  bony  attach- 
ments; instead,  it  originates  from  the  dermis 
along  the  supraorbital  ridge  and  inserts  within 
the  galea  aponeurotica.  Contraction  of  the  fron- 
talis results  in  elevation  of  the  brows  and  cre- 
ates horizontal  forehead  rhytids. 

The  procerus  muscle  is  also  oriented  in  a 
vertical  fashion  and  located  centrally  on  the  gla- 
bellar area  where  it  interdigitates  with  inferior 
fibers  of  the  frontalis  muscle.  It  originates  at  the 


370  J La  State  Med  Soc  VOL  1 52  August  2000 


nasal  bones  and  upper  lateral  nasal  cartilages 
and  inserts  within  the  dermis  of  the  forehead 
between  the  brows.  Its  action  lowers  the  heads 
of  the  brows  and  is  responsible  for  horizontal 
wrinkles  at  the  radix  of  the  nose. 

The  depressor  supercilii  muscles  originate  at 
the  frontal  process  of  the  frontal  bone  and  insert 
within  the  dermis  of  the  head  of  the  eyebrows. 
These  are  the  most  superficial  mimetic  muscles, 
lying  on  top  of  both  the  lateral  procerus  and 
medial  orbicularis  oculi.  Isse  believes  their  ac- 
tion was  confused  with  the  corrugator  supercilii 
for  many  years,  as  open  approaches  to  brow  lift- 
ing presented  skewed  anatomy  when  the  fore- 
head flap  was  folded  upon  itself,  obscuring  the 
presence  of  the  depressor  supercilii.1  It  is  de- 
scribed that  these  muscles  depress  the  heads  of 
the  brows  and  produce  vertical  frown  lines  in 
the  glabellar  area. 

The  corrugator  supercilii  muscles  originate 
at  the  superior-medial  orbital  rim  and  insert  into 
the  dermis  along  the  length  of  the  brows.  Most 
believe  contraction  of  these  muscles  pulls  the 
brows  inferior-medially,  creating  vertical  glabel- 
lar wrinkles.  They  are  the  deepest  mimetic 
muscles  whose  fibers  must  pierce  through  the 
frontalis  and  orbicularis  oculi  to  insert  into  the 
dermis. 

The  final  mimetic  muscle  of  the  upper  one 
third  of  the  face  is  the  orbital  portion  of  the  or- 
bicularis oculi.  It  is  a sphincteric  muscle  origi- 
nating at  the  frontal  process  of  the  maxilla  and 
medial  angle  of  the  eye  with  some  fibers  insert- 
ing at  the  dermis  of  the  brow.  Contraction  de- 
presses the  entire  brow  and  its  lateral  fibers  are 
responsible  for  lateral  orbital  wrinkles  known 
as  'crow's  feet'. 

The  motor  function  of  these  five  mimetic 
muscles  is  supplied  by  the  frontal  branch  of  the 
facial  nerve  (cranial  nerve  VII),  with  all  but  the 
frontalis  muscle  also  receiving  variable  innerva- 
tion from  the  zygomatic  branch.  Sensory  inner- 
vation of  the  face  is  supplied  by  the  trigeminal 
nerve  (cranial  nerve  V).  The  brow  is  supplied 
by  the  superior  (ophthalmic)  division  which  di- 
vides into  the  supratrochlear  and  supraorbital 
nerves.  These  branches  exit  the  orbit  via  notches 


of  the  same  names,  with  a small  percentage  of 
patients  having  true  foramina  providing  egress. 
These  two  nerves  pierce  the  corrugator  supercilii 
muscle  and  travel  along  the  superficial  surface 
of  the  frontalis  muscle  in  a vertical  direction.  The 
supratrochlear  nerve  is  found  1.7  cm  from  the 
midline  and  provides  sensation  to  the  conjunc- 
tiva, upper  lid,  and  inferior-medial  forehead. 
The  supraorbital  nerve  is  2.7  cm  from  the  mid- 
line and  supplies  sensory  innervation  to  the 
upper  lid,  forehead,  and  anterior  scalp. 

Running  in  tandem  with  the  supratrochlear 
and  supraorbital  nerves  are  arteries  of  the  same 
names.  Along  with  the  dorsal  nasal  artery,  all 
three  are  terminal  vessels  of  the  internal  carotid 
system  via  the  ophthalmic  artery.  The  largest 
area  of  the  scalp  is  supplied  by  a branch  of  the 
external  carotid  artery,  the  superficial  temporal 
artery.  All  of  these  vessels  form  a rich  anasto- 
motic network  located,  along  with  the  sensory 
nerves,  along  the  superficial  surface  of  the  fron- 
talis muscle.  It  is  this  abundant  vascular  supply 
to  the  face  that  makes  the  risk  of  infection  and 
skin  flap  necrosis  extremely  rare. 

From  the  perspective  of  the  facial  plastic  sur- 
geon, it  is  helpful  to  visualize  the  upper  one  third 
of  the  face  as  three  separate  subunits  - central 
forehead,  laterally  flanking  temporal  fossae,  and 
paired  brows.  This  categorization  allows  for  dif- 
ferentiation of  areas  with  slight  variations  in 
surgical  anatomy  and  also  facilitates  the  aesthetic 
evaluation  of  the  aging  forehead-brow  complex. 

The  central  compartment  is  composed  of  the 
forehead,  the  largest  subunit  of  the  upper  face. 
Most  aesthetic  procedures  will  involve  some 
degree  of  dissection  within  the  forehead  so  it  is 
important  to  understand  the  anatomic  layers  of 
this  region  in  order  to  plan  the  appropriate  ap- 
proach and  spare  vital  structures.  The  mnemonic 
SCALP  is  widely  used  as  a memory  tool  for  the 
five  layers  of  the  scalp  and  may  also  be  applied 
to  the  forehead.  The  Skin  and  underlying 
subcutaneous  tissue  form  a relatively  inelastic 
layer.  The  fibrous  septae  connecting  subcutane- 
ous fat  to  the  underlying  galea  Aponeurotica 
contain  the  important  neurovascular  structures 
described  previously.  The  galea  is  the  fibromus- 


J La  State  Med  Soc  VOL  152  August  2000  371 


cular  extension  of  the  SMAS  (superficial  mus- 
culoaponeurotic  system)  which  envelops  the 
mimetic  muscles  of  the  lower  face.  In  a similar 
fashion,  the  frontalis  muscle  is  ensheathed  by 
the  galea.2  These  three  superficial  layers  are  able 
to  slide  easily  over  the  Loose  connective  tissue 
covering  the  final  layer,  the  Periosteal  covering 
of  the  skull.  Of  additional  interest  is  the  arcus 
marginalis,  a thickening  of  connective  tissue 
adherent  to  the  orbital  rims  where  the  skull  pe- 
riosteum becomes  contiguous  with  the  inner 
periorbital  covering  of  the  orbits. 

The  lateral  compartments  contain  the  tem- 
poral fossae  whose  tissue  layers  differ  slightly 
from  those  of  the  forehead.  The  SCALP  mne- 
monic is  useful  for  examining  these  differences. 
Similar  to  the  forehead,  the  first  two  layers  con- 
sist of  Skin  and  subcutaneous  tissue.  Instead  of 
the  galea  Aponeurotica,  the  middle  layer  is  the 
temporoparietal  fascia.  Since  the  SMAS  becomes 
discontinuous  at  the  zygomatic  arch,  the  tem- 
poroparietal fascia  is  referred  to  as  an  analogue 
of  the  SMAS.  This  layer  is  vitally  important  re- 
garding surgical  anatomy  because  it  contains  the 
frontal  branch  of  the  facial  nerve  as  well  as  the 
superficial  temporal  artery  and  vein.  The  next 
underlying  layer  consists  of  Loose  connective 
tissue  which  overlies  the  final  layer,  the  deep 
temporal  fascia  covering  the  temporalis  muscle. 

The  deep  temporal  fascia  becomes  contigu- 
ous with  the  Periosteum  of  the  skull  and  forms 
the  conjoint  fascia  of  the  superior  temporal  line 
- the  anterior  border  of  the  temporalis  muscle 
as  well  as  the  boundary  between  lateral  and  cen- 
tral subunits.  The  deep  temporal  fascia  splits  2 
to  3 cm  above  the  zygomatic  arch  to  ensheath 
the  temporal  fat  pad  and  then  splits  again  to  at- 
tach to  the  arch.  These  split  layers  are  known  as 
the  superficial  and  deep  layers  of  the  deep  tem- 
poral fascia.  This  area  is  important  regarding 
surgical  anatomy  because  dissection  within  the 
temporal  fat  pad  avoids  injury  to  the  facial  nerve 
by  using  the  superficial  layer  of  the  deep  tem- 
poral fascia  as  a barrier. 

Familiarity  with  the  course  of  the  facial  nerve 
is  extremely  important  for  avoiding  surgical 
complications  in  this  area.  Its  course  is  roughly 


approximated  by  a line  drawn  0.5  cm  anterior 
to  the  tragus  to  1.5  cm  lateral  to  the  lateral  brow. 
The  frontal  branch  exits  the  parotid  gland  ante- 
rior to  the  superficial  temporal  artery  and  crosses 
over  the  midportion  of  the  zygomatic  arch.  At 
this  point  the  nerve  is  most  vulnerable  as  it  trav- 
els superficially  above  the  periosteum.  It  then 
enters  the  temporal  fossa  and  travels  within  the 
temporoparietal  fascia.  The  nerve  then  crosses 
through  the  superior  temporal  line  to  enter  the 
forehead  at  the  lateral  aspect  of  the  frontalis, 
where  it  continues  travelling  along  the  deep  sur- 
face of  the  muscle.  It  is  important  to  remember 
that  in  the  lower  face  peripheral  branches  of  the 
facial  nerve  travel  below  the  SMAS,  whereas 
above  the  zygomatic  arch  the  frontal  branch  trav- 
els within  the  SMAS  (analogue). 

The  anatomic  layers  of  the  third  subunit  are 
the  same  as  those  of  the  forehead.  The  brows 
are  deemed  a separate  subunit  because  of  the 
dominant  role  they  play  in  the  aesthetic  frame- 
work of  the  upper  face.  Generally,  the  accepted 
ideal  forehead  height  is  equal  to  one  third  of  the 
entire  vertical  dimension  of  the  face.  This  usu- 
ally measures  5 cm.  The  ideal  proportions  of  the 
brows  are  not  as  standard  and  have  been  the 
subject  of  many  studies.  Caucasian  brow  posi- 
tion and  shape  is  classically  described  as  a club- 
shaped  head  of  the  brow  beginning  medially  at 
a vertical  line  running  tangent  to  the  lateral  na- 
sal ala  through  the  medial  canthus.  The  brow 
tapers  laterally  and  ends  at  a point  defined  by 
an  oblique  line  drawn  tangent  to  the  lateral  na- 
sal ala  and  through  the  lateral  canthus.  Both  ends 
of  the  brow  should  lie  at  the  same  horizontal 
level  with  the  midportion  arching  superiorly. 
The  apex  of  this  arch  is  located  on  a vertical  line 
through  the  lateral  limbus  of  the  eye.3  Some 
believe  this  model  creates  an  unnatural  sur- 
prised look  and  suggest  the  apex  of  the  arch 
should  be  positioned  more  laterally  over  the  lat- 
eral canthus.4  It  is  generally  agreed  though  that 
the  female  brow  should  arch  above  the  supraor- 
bital rim,  while  in  males  it  should  lie  at  the  level 
of  the  orbital  rim. 

When  the  natural  positions  of  the  three  sub- 
units are  disrupted,  the  result  is  an  unpleasant 


372  J La  State  Med  Soc  VOL  1 52  August  2000 


visage.  Congenital  deformities,  soft  tissue 
trauma,  and  nerve  damage  may  all  cause  such  a 
disruption,  but  the  most  common  etiology  is 
aging.  The  stigmata  of  the  aging  upper  face  in- 
clude fine  and  deep  rhytids,  brow  ptosis,  and 
lateral  hooding  of  the  eyes.  Patients  suffering 
these  deformities  complain  of  appearing  tired, 
angry,  or  sad. 

The  intrinsic  process  of  aging  creates  fine 
wrinkles  as  microscopic  changes  result  in  skin 
laxity.  These  changes  include  degeneration  of 
organized  elastic  fibers,  collagen  fiber  loss,  vas- 
cular decay,  and  dermal  atrophy.  The  process  is 
exacerbated  by  actinic  damage  and  smoking. 

Deep  rhytids  develop  secondary  to  the 
chronic  action  of  facial  musculature.  Skin 
wrinkles  as  underlying  muscle  contraction 
causes  simultaneous  bunching  of  the  tightly 
adherent  dermis.  Eventually,  the  muscular  fas- 
cia contracts  within  these  furrows  and  perma- 
nent skin  creases  are  developed.  These  are  vis- 
ible even  when  the  muscles  are  at  rest.  Horizon- 
tal rhytids,  glabellar  frown  lines,  and  the  hori- 
zontal wrinkle  of  the  nasion  are  classically  asso- 
ciated with  hyperactivity  of  the  frontalis,  corru- 
gator  supercilii,  and  procerus  muscles,  respec- 
tively. 

This  process  can  occur  in  younger  patients 
secondary  to  habitual  frowning;  however,  in 
older  patients  muscle  hyperactivity  is  often  re- 
lated to  brow  ptosis.  Aging  causes  descent  of  the 
brows.  As  the  forehead  stretches  secondary  to 
skin  laxity  and  loss  of  tissue  support  allows 
downward  movement,  the  lowered  brow  creates 
decreased  vision  in  the  upper  fields.  The  invol- 
untary response  is  to  chronically  contract  the 
frontalis  muscle  to  raise  the  brows  and  compen- 
sate for  their  descent.  This  hyperactivity  creates 
deep  horizontal  rhytids  and  an  older-appearing 
face.  Persistent  contraction  can  also  produce 
chronic  headaches  which  are  often  worse  at  the 
end  of  the  day. 

Skin  laxity  and  gravity  should  produce  a 
uniform  ptosis  of  the  brow;  however,  it  is  often 
the  lateral  brow  which  descends  first,  creating 
the  appearance  of  lateral  hooding  over  the  eyes. 
This  phenomenon  is  explained  by  the  relative 


lack  of  soft  tissue  support  in  the  temporal  fos- 
sae. The  result  is  a face  which  appears  tired  and 
aged.  Lateral  hooding  secondary  to  brow  ptosis 
is  often  the  diagnosis  when  patients  request  an 
upper  lid  blepharoplasty.  Brow  ptosis  may  ac- 
centuate existing  blepharochalasis  (redundant 
upper  lid  skin).  Blepharoplasty  alone  can  not 
correct  this  problem,  and,  by  excessive  skin  re- 
section and  resultant  unnatural  fixation  of  the 
brow,  may  make  the  problem  worse.  Often,  brow 
lift  alone  corrects  the  problem.  If  additional  work 
is  required,  the  blepharoplasty  should  always 
be  performed  second.4 

Accurate  evaluation  of  the  upper  face  is  de- 
pendent on  proper  positioning.  The  patient 
should  be  sitting  erect,  with  facial  muscles  re- 
laxed, and  eyes  in  a neutral  gaze.  Often,  patients 
suffering  involuntary  frontalis  contraction  sec- 
ondary to  brow  ptosis  must  be  instructed  to  fully 
relax  this  muscle.  The  surgeon  should  examine 
for  the  stigmata  of  aging  - fine  and  deep  rhytids, 
brow  ptosis,  lateral  hooding  — as  well  as  posi- 
tion and  quality  of  the  hairline  and  any  asym- 
metry. Evaluation  for  brow  ptosis  is  assisted  by 
the  brow  elevation  test.  The  surgeon  manually 
lifts  both  brows  to  a more  aesthetically  pleasing 
position.  The  amount  of  lift  required  is  noted. 

Before  performing  any  procedure  that  might 
affect  vision,  one  should  document  preoperative 
acuity  and  visual  fields.  Additionally,  to  assist 
intraoperative  decisions,  photographs  are  taken 
in  the  AP  view  of  the  patient  relaxed,  smiling, 
squinting,  or  raising  brows,  and  also  lateral 
views. 

Each  patient  will  have  a combination  of  ab- 
normalities. The  facial  plastic  surgeon  has  sev- 
eral options  for  plane  of  dissection,  incision 
placement,  and  operative  technique  from  which 
to  individualize  the  approach  needed  to  address 
the  patient's  specific  problems.  Understanding 
the  available  planes  of  dissection  helps  in  choos- 
ing the  operative  technique.  The  subcutaneous 
plane  provides  the  most  control  over  brow  po- 
sition because  of  the  relative  pliability  of  the  thin 
flap  and  the  ability  to  separate  the  many  dermal 
attachments  to  underlying  muscles  of  expres- 
sion. It  also  has  the  advantage  of  sparing  sen- 


J La  State  Med  Soc  VOL  152  August  2000  373 


sory  nerves,  thus  avoiding  postoperative  anes- 
thesia, because  the  incision  does  not  violate  the 
galea.  Disadvantages  to  this  plane  include  in- 
creased technical  difficulty  and  operative  time, 
as  well  as  an  increased  incidence  of  skin  slough 
and  alopecia  secondary  to  vascular  insult. 

Dissection  in  the  subgaleal  plane  is  techni- 
cally easy  and  results  in  a well-vascularized  skin 
flap.  The  loose  connective  tissue  layer  underly- 
ing the  galea  contains  numerous  blood  vessels 
which  are  easily  constricted  with  local  epineph- 
rine, creating  an  advantageous  avascular  dissec- 
tion plane.  Major  disadvantages  include  com- 
plete sensory  denervation  posterior  to  the  inci- 
sion, due  to  transection  of  the  nerves  running 
along  the  galea,  and  decreased  ability  to  address 
rhytids  secondary  to  greater  flap  thickness. 

Dissection  in  the  subperiosteal  plane  is  also 
technically  easy  and  produces  a flap  with  excel- 
lent blood  supply.  It  shares  the  same  disadvan- 
tage of  the  subgaleal  approach  of  postoperative 
anesthesia  posterior  to  the  incision  with  an  even 
more  decreased  ability  to  address  rhytids  sec- 
ondary to  the  relative  inelasticity  of  the  perios- 
teum. 

Another  aspect  to  consider  when  deciding 
upon  brow  lift  technique  is  the  need  for  manipu- 
lation of  the  mimetic  musculature.  Owing  to 
their  prominent  role  in  producing  deep  rhytids, 
most  authors  advocate  addressing  the  corruga- 
tor  supercilii  and  procerus  muscles  as  well  as 
the  orbital  portion  of  the  orbicularis  oculi 
muscle.  Simple  scoring  of  the  muscle  bellies  will 
result  in  return  of  function  within  4 to  6 months. 
Resection  can  be  undertaken  under  direct  visu- 
alization using  any  of  the  dissection  planes,  but 
care  must  be  exercised  to  avoid  injury  to  the  su- 
pratrochlear neurovascular  bundle  as  it  traverses 
through  the  corrugator  supercilii  muscle.  Cur- 
rently we  advocate  using  Botulinum  toxin 
(BoTox)  2 weeks  prior  to  performing  endoscopic 
browlift  in  order  to  mitigate  the  action  of  these 
muscles,  because  over-resection  can  create  a 
noticeable  surface  depression  and  produce  un- 
natural widening  of  the  medial  brows. 

Manipulation  of  the  frontalis  muscle  is  con- 
troversial. Some  authors  advocate  scoring  or 


minimal  resection  in  all  cases,  while  the  major- 
ity agree  this  may  be  indicated  only  in  the  rare 
case  of  deep  forehead  rhytids  without  brow  pto- 
sis. Generally  it  is  desirable  to  prevent  weaken- 
ing of  the  frontalis,  because  without  its  elevat- 
ing action,  the  brow  becomes  ptotic.  This  coun- 
teracts any  effects  of  the  browlift  procedure  and 
stimulates  frontalis  hyperactivity  and  subse- 
quent rhytids. 

SURGICAL  TECHNIQUES 

The  direct  brow  lift  offers  the  most  precise  con- 
trol of  brow  position.  The  incision  in  the  imme- 
diate suprabrow  area  allows  selective  skin  exci- 
sion using  the  subcutaneous  dissection  plane 
and  does  not  address  the  mimetic  muscles.  Its 
main  disadvantage,  rendering  it  seldom  used, 
is  a noticeable  scar.  The  difference  in  skin  thick- 
ness above  and  below  the  incision,  as  well  as 
the  loss  of  fine  upper  brow  hair  creating  an  un- 
sightly sharply-defined  upper  brow  margin, 
make  camouflage  of  the  incisional  scar  virtually 
impossible.4  This  technique  is  indicated  for  pa- 
tients with  functional  brow  abnormalities,  such 
as  unilateral  ptosis,  who  are  less  concerned  with 
cosmesis. 

The  midforehead  lift  is  a variation  of  the  di- 
rect brow  lift  in  which  the  incisions  are  hidden 
within  deep  forehead  rhytids.  Using  creases  at 
different  levels  on  each  side  further  camouflages 
the  scars.  This  technique  likewise  offers  excel- 
lent positional  control  of  the  brows  due  to  the 
proximity  of  its  incision  and  subcutaneous  plane 
of  dissection.  Lack  of  hairline  distortion  and  abil- 
ity to  hide  scars  make  it  ideal  for  patients  with 
high  foreheads  or  male-pattern  baldness  along 
with  the  required  deep  furrows.  This  technique 
will  not  address  ptosis  of  the  lateral  subunits  or 
lateral  hooding  but  does  provide  access  for  ma- 
nipulation of  the  corrugator  supercilii  muscles. 

The  coronal  forehead  lift  was  first  popular- 
ized as  a versatile  technique  using  the  subgaleal 
or  subperiosteal  plane.  It  allows  direct  manipu- 
lation of  the  mimetic  muscles,  and  placement  of 
the  incision  5 cm  behind  the  hairline  produces  a 
well-hidden  scar.  Disadvantages  of  the  necessary 


374  J La  State  Med  Soc  VOL  152  August  2000 


wide  undermining  include  an  increased  risk  of 
both  hematoma  formation  and  nerve  injury  as 
well  as  a protracted  convalescent  period  (5  to  7 
days).  In  addition,  there  are  the  risks  of  alope- 
cia along  the  incision,  as  well  as  elevation  of  the 
hairline;  therefore,  this  technique  is  little  used 
in  patients  with  thin  hair,  baldness,  or  high  fore- 
heads. 

Patients  with  a high  forehead,  that  is  a fore- 
head height  greater  than  5 cm,  should  be  ad- 
dressed using  the  pre-trichial  incision.  This  ap- 
proach decreases  forehead  height  by  excising 
non-hairbearing  skin,  while  preserving  the  ex- 
isting hairline.  The  incision  is  placed  at  the  an- 
terior forehead-hairline  junction  for  the  middle 
two  thirds  of  the  brow  and  extends  into  the  lat- 
eral subunits  2 cm  behind  the  hairline.  By  bev- 
elling in  a posterior  to  anterior  direction,  the  un- 
derlying hair  follicles  are  left  intact.  After  excis- 
ing excess  skin,  the  incision  is  reapproximated 
and  hair  eventually  grows  through  the  scar,  ef- 
fectively hiding  it.5 

The  main  advantage  of  the  pre-trichial  tech- 
nique is  preservation  of  the  hairline.  It  is  there- 
fore utilized  in  patients  whose  forehead  height 
will  not  tolerate  farther  elevation.  The  dissection 
is  within  the  subgaleal  plane  and  allows  direct 
manipulation  of  the  mimetic  muscles.  Disadvan- 
tages include  increased  scalp  anesthesia,  because 
the  incision  is  located  further  anterior  than  its 
coronal  counterpart,  and  an  unsightly  scar  if 
meticulous  skin  closure  is  not  achieved. 

The  final  technique  is  the  endoscopic  brow 
lift.  It  is  quickly  becoming  the  method  of  choice 
for  addressing  the  stigmata  of  aging  in  the  up- 
per face.  Its  advantages  are  numerous.  Excellent 
visualization  allows  decreased  risk  of  nerve  in- 
jury and  better  manipulation  of  facial  muscula- 
ture. Small,  hidden  incisions  avoid  scarring  and 
alopecia,  better  preserve  sensory  innervation  of 
the  scalp,  and  allow  shorter  convalescence  by 
lessening  disruption  of  venous  and  lymphatic 
channels.  The  disadvantages  to  utilizing  this 
newer  technology  include  cost  and  additional 
training. 

The  endoscopic  technique  allows  correction 
of  all  the  stigmata  of  aging  - brow  ptosis,  tem- 


poral ptosis  with  lateral  hooding,  and  rhytids. 
Several  relative  contraindications  exist.  The  sub- 
periosteal plane  of  dissection,  coupled  with  the 
distant  placement  of  incisions,  does  not  allow 
precise  positioning  of  the  brows.  Superior  move- 
ment of  the  hairline  (relative  to  the  skull,  not  the 
brows)  can  be  expected,  so  patients  with  high 
foreheads  are  avoided.  Patients  with  thick,  se- 
baceous skin  are  also  not  good  candidates. 

There  are  numerous  methods  of  fixation  for 
endoscopic  browlift.  Early  technique  consisted 
of  nothing  but  an  external  compression  dress- 
ing. This  was  inadequate  and  led  to  frequently 
recurrent  brow  ptosis.  Today,  there  exist  a vari- 
ety of  methods  which  serve  to  support  the  lifted 
soft  tissues. 

Methods  of  soft  tissue  anchoring  include 
scalp  plication,  attachment  of  anterior  galea  to 
posterior  galea,  or  inverted  T to  V skin  advance- 
ment. These  have  the  disadvantage  of  not  being 
affixed  to  stable  bone,  therefore,  their  results  are 
unpredictable.6 

Microscrews  are  involved  in  many  popular 
techniques.  Sutures  attached  to  underlying  galea 
and/or  periosteum  may  be  anchored  to 
miniscrews.  The  advantage  of  rigid  fixation  is  a 
long-lasting  lift  of  soft  tissues.7  The  disadvan- 
tages include  the  possibility  of  intracranial  place- 
ment, patient  reluctance  to  accept  hardware,  and 
screws  or  plates  which  are  palpable.  The  use  of 
absorbable  screws  avoids  the  latter  two  concerns. 

A variation  of  rigid  fixation  is  the  creation  of 
a bone  bar  from  the  skull  itself.  Using  a cutting 
burr  at  a 30  degree  angle,  a trough  is  formed  in 
the  outer  cortex.  The  resulting  tunnel  provides 
a support  point  for  the  attachment  of  sutures,  in 
the  same  manner  as  screws  or  plates.  Advan- 
tages to  this  method  include  avoidance  of  exter- 
nal hardware,  with  their  added  cost,  possibility 
of  being  palpable,  and  occasional  need  for  re- 
moval. Disadvantages  are  the  risk  of  disrupting 
emissary  veins,  possible  intracranial  extension, 
and  difficulty  of  suture  attachment.8 

These  last  two  disadvantages  were  ad- 
dressed by  Kobienia  et  al9  who  developed  a U- 
shaped  trough  which  they  report  is  technically 
easier  to  create  than  a cortical  tunnel,  facilitates 


J La  State  Med  Soc  VOL  1 52  August  2000  375 


suture  attachment,  and  allows  better  visualiza- 
tion which  decreases  risk  of  intracranial  exten- 
sion. 

In  conclusion,  evaluation  of  the  aging  upper 
face  is  rooted  in  comprehensive  knowledge  of 
anatomy,  understanding  of  the  effect  of  time  and 
gravity  on  soft  tissues,  and  appreciation  of  aes- 
thetic ideals.  Familiarity  with  the  various 
browlift  techniques  allows  the  surgeon  to  ad- 
dress the  individual's  unique  needs  with  the 
proper  procedure  and  successfully  create  a more 
youthful  appearance. 

REFERENCES 

1.  Isse  NG.  Endoscopic  forehead  lift:  evolution  and 
update.  Clin  Plast  Surg  1995;22:661-673. 

2.  Sykes  JM.  Applied  anatomy  of  the  forehead  and 
brow.  Facial  Plast  Surg  Clin  1997;5:99-112. 

3.  Sullivan  MJ.  Brow  and  forehead  aesthetics.  Facial 
Plast  Surg  Clin  1997;5:95-98. 

4.  Cook  TA,  Brownrigg  PJ,  Wang  TD,  et  al.  The  Versa- 
tile Midforehead  Browlift.  Arch  Otolaryngol  Head 
Neck  Surg  1989;115:163-168. 


5.  Kerth  JD,  Toriumi  DM.  Management  of  the  aging 
forehead.  Arch  Otolaryngol  Head  Neck  Surg 
1990;116:1137-1142. 

6.  Graham  HD.  Methods  of  soft-tissue  fixation  in  en- 
doscopic surgery.  Facial  Plast  Surg  Clin  North  Am 
1997;5:145-154. 

7.  Graham  HD,  Core  GB.  Endoscopic  forehead  lifting 
using  fixation  sutures.  Operative  Tech  Otolaryngol 
Head  Neck  Surg.  1995;8:245-252. 

8.  Newman  JP,  LaFerriere  KA,  Koch  RJ,  et  al. 
Transcalvarial  suture  fixation  for  endoscopic  brow 
lifts.  Arch  Otolaryngol  Head  Neck  Surg.  1997;123:313- 
317. 

9.  Kobienia  BJ,  Beek  AV.  Calvarial  fixation  during 
endoscopic  brow  lift.  Plast  Reconstr  Surg  1998;238- 
240. 


Dr  Brodner  is  a resident  with  the  Department  of 
Otolaryngology  - Head  and  Neck  Surgery 
at  Tulane  University  School  of  Medicine 
in  New  Orleans , Louisiana. 

Dr  Graham  is  Clinical  Assistant  Professor  with  the 
Departments  of  Otolaryngology  - Head  and  Neck  Surgery 
and  Facial  Plastic  Surgery  at  Ochsner  Clinic  and  Tulane 
University  School  of  Medicine  in  New  Orleans , Louisiana. 


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376  J La  State  Med  Soc  VOL  152  August  2000 





Incidental  Discovery  on  Mammography 
Done  for  a Palpable  Breast  Mass 

Sanjay  M.  Patel,  MD;  Jane  Clayton,  MD,  PhD;  Harold  Neitzschman,  MD 


A 32-two-year-old  woman  complains  of  a palpable  lump  in  her  left  breast.  Her  past  medical 
and  family  history  is  non-contributory.  There  was  no  palpable  lump  on  clinical  breast 
examination.  A mammogram  was  performed. 


Image  la  and  Image  1b.  CC  and  MLO  views  of  both  breasts. 


What  is  your  diagnosis? 
Elucidation  is  on  page  378. 


J La  State  Med  Soc  VOL  152  August  2000  377 


REFERENCES 


Radiology  Case  of  the  Month 
Case  Presentation  is  on  page  377. 

RADIOLOGIC  DIAGNOSIS  - Granular  cell 
tumor 

INTERPRETATION  OF  IMAGES 

Images  la  and  lb,  CC  and  MLO  views,  demon- 
strate a predominantly  fatty  replaced  breast.  A 
2 cm  high-density  mass  with  irregular  spicu- 
lated  margins  (arrow)  is  seen  in  the  posterior 
aspect  of  the  left  breast  in  the  inner  upper  quad- 
rant. There  are  no  associated  calcifications.  No 
mammographic  abnormality  is  seen  in  the  sus- 
pected location  of  the  patient's  palpable  lump. 

Image  2,  spot  compression  views  shows  the 
mass  with  irregular  margins  (arrow). 

DISCUSSION 

Granular  cell  tumor  (formerly  known  as  granu- 
lar cell  myoblastoma)  is  a benign,  locally  ag- 
gressive tumor.  The  tumor  originates  from 
Schwann  cells.1  Granular  cell  tumors  occur  in 
a wide  variety  of  visceral  and  cutaneous  sites, 
including  the  tongue.2  Approximately  6%  oc- 
cur in  the  breast.1-3 

Women  are  more  frequently  affected  then 
men.  The  average  age  of  presentation  is  in  the 
thirties.  The  majority  of  granular  cell  tumors 
occur  in  the  upper  inner  quadrant.  Although 
the  tumors  are  benign,  they  may  be  locally  in- 
filtrative and  must  be  completely  excised  with 
clear  margins  to  prevent  recurrence.3  The  ma- 
jority of  tumors  are  cured  by  wide  local  exci- 
sion.13 

Granular  cell  tumors  may  mimic  carcinoma 
on  clinical  breast  examination,  mammography, 
and  ultrasound.  Clinically,  the  tumor  may  be  a 
hard  palpable  mass,  sometimes  fixed  and  asso- 
ciated with  skin  retraction.  On  mammography, 
the  mass  is  round  or  oval  with  spiculated  or 
indistinct  margins.  Histopathology  is  necessary 
to  make  the  diagnosis. 


1.  Jackson  VP,  Jahan  R,  Fu  YS.  Benign  Breast  Lesions. 
In:  Basset  LW,  Jackson  VP,  Jahan  R,  et  al.  Diagnosis 
of  Diseases  of  the  Breast.  Philadelphia,  Pa:  WB 
Saunders;  1997:437-439. 

2.  Tavassoli  FA.  Mesenchymal  Lesions.  In:  Tavassoli 
FA.  Pathology  of  the  Breast.  Bethesda,  Md:  Appleton 
& Lange;  1992:535-537. 

3.  Kopans  DB.  Pathologic,  Mammographic,  and 
Sonographic  Correlation.  In:  Kopans  DB.  Breast 
Imaging.  Boston,  Mass:  Lippincott-Raven;  1998:560- 
561. 


Dr  Patel  is  a fellow  at  Louisiana  State  University 
Health  Sciences  Center,  New  Orleans,  Louisiana. 

Dr  Clayton  is  an  associate  professor  of  Radiology  at 
Louisiana  State  University  Health  Sciences  Center, 

New  Orleans,  Louisiana. 

Dr  Neitzschman  is  a professor  of  Radiology  at 
Tulane  Medical  Center,  New  Orleans,  Louisiana. 


378  J La  State  Med  Soc  VOL  152  August  2000 


History  of  Medicine 


A Clinical  Report  on  Intravenous  Saline 
Infusion  in  the  Wards  of  the  New  Orleans 
Charity  Hospital  From  June  1888  to  June  1891 


Gustavo  Colon,  MD 


The  following  is  an  excerpt  from  an  article  by 
Rudolph  Matas , MD,  which  appeared  in  the 
August  1891  issue  of  the  Journal. 


"It  should  be  remembered  that  the  term  trans- 
fusion should  be  restricted,  as  Roussel  first  in- 
dicated, to  that  method  of  intravascular  medi- 
cation by  which  the  blood  of  one  person  or  ani- 
mal is  transferred  from  the  vascular  system  of 
one  into  the  vascular  system  of  the  other  and 
that  the  term  infusion  (intravenous,  intra-peri- 
toneal  or  subcutaneous)  should  be  restricted  to 
all  cases  in  which  other  solutions  or  media  than 
blood  are  introduced.  The  injection  of  blood  also, 
if  not  done  directly  into  vascular  system  as  in 
the  subcutaneous  injection  of  blood  (eg,  Karst's 
or  V.  Ziemessen's  method),  cannot  properly  be 
called  transfusion. 

"Without  attempting  to  establish  a lengthy 
parallel  between  the  older  practice  of  transfu- 
sion and  the  more  modern  method  of  saline  in- 


fusion for  the  restoration  of  patients  threatened 
with  death  from  the  rapid  depletion  of  their  vas- 
cular system,  we  may  at  once  ask:  is  this  saline 
infusion  a true  rival  or  a mere  succedaneum  of 
blood  transfusion?  We  must  answer  yes  and  no, 
according  to  certain  circumstances. 

"We  must  at  once  state  that  mechanically  or 
physically,  saline  infusions  are  the  rivals  or 
equivalents  of  blood  transfusion,  while  physi- 
ologically they  never  can  rival  or  equal  the  value 
of  blood. 

"In  speaking  of  blood  as  a medium  for  trans- 
fusion we  mean,  of  course,  only  pure,  entire,  liv- 
ing blood  and  not  the  altered  pathological  ma- 
terial known  as  defibrinated  blood.  We  also 
mean  blood  of  the  same  species  and  not  that 
derived  from  heterogeneous  sources. 

"Now  the  superiority  of  entire  and  living 
blood  is  based  on  three  qualities,  viz:  1.  Its  nu- 
tritive. 2.  Its  respiratory.  3.  Its  hemogenic  value. 

"None  of  these  qualities,  except  the  last  per- 
haps, are  possessed  by  the  inorganic  saline  so- 


J La  State  Med  Soc  VOL  152  August  2000  379 


lution.  Consequently,  we  need  not  discuss  fur- 
ther the  physiological  superiority  of  blood  which 
is  here  unhesitatingly  admitted. 

"But  it  happens  in  surgical  practice  that  in 
many,  if  not  the  vast  majority  of  the  cases  of  acute 
anemia  in  which  fatal  syncope  threatens  life 
through  vascular  depletion,  that  the  cry  of  the 
moment  is  not  for  physiological  restitution  so 
much  as  for  the  mechanical  dilution  of  the  blood 
remaining  in  the  vascular  system  and  tissues  of 
the  individual;  under  these  circumstances,  the 
true  value  of  saline  solutions  is  made  clear  and 
its  position  as  a true  rival  of  the  more  costly 
blood  can  be  readily  appreciated. 

"The  question  of  the  utility  of  neutral  saline 
solutions  and  their  ability  to  save  the  life  of  pa- 
tients apparently  moribund  from  loss  of  blood 
having  been  decided  in  the  affirmative  by  su- 
perabundant clinical  experience,  a more  impor- 
tant problem  remained  to  be  solved  and  that 
was,  what  was  the  limit  of  this  life-saving  power. 
When  could  the  action  of  the  saline  solution  be 
expected  to  be  permanent  and  when  only  tran- 
sitory or  ephemeral? 

"This  problem  was  easily  solved  by  the 
physiologist  in  his  experimental  laboratory  but 
not  so  readily  by  the  clinician. 

"The  physiological  limit  of  blood  loss  com- 
patible with  life  has  been  the  object  of  interest- 
ing and  serious  experimental  study.  From  the 
earlier  studies  of  Herbst  (1822)  to  those  of 
Renaut,  Hayem,  Wanner  and  Kermisson  to  the 
latest  calculations  of  Rosenberg,  we  may  admit 
that  animals  can  survive  the  rapid  loss  of  two- 
fifths  of  the  total  quantity  of  their  blood,  while 
the  loss  of  more  than  two-fifths  and  less  than 
one-half  is  usually,  and  more  than  one-half  ab- 
solutely fatal.  In  his  experimental  use  of  the  .7 
per  cent  salt  solution,  this  investigator  was  led 
to  think  that  the  injections  only  temporarily  pro- 
longed life  in  hemorrhages  beyond  one-half  the 
total  quantity  of  blood.  This,  he  believed,  was 
due  to  the  reduction  of  the  absolute  number  of 
corpuscles  in  a given  bulk,  resulting  in  a quali- 
tative anemia. 

"Returning  now  to  the  clinical  aspect  of  this 
subject,  we  must  note  that  a certain  amount  of 


shock  is  almost  inseparable  from  the  acute  ane- 
mia that  the  surgeon  is  called  upon  to  meet,  and 
we  may  at  once  state  that  it  is  the  proportion  in 
which  this  element  of  shock  is  added  to  the  ane- 
mic element  that,  as  a general  rule,  decides  the 
permanency  of  the  therapeutic  benefit  obtained 
by  saline  infusion.  From  the  limited  experience 
furnished  by  the  nineteen  cases  reported  in  the 
first  part  of  this  paper,  and  a careful  consider- 
ation of  many  other  cases  scattered  in  the  litera- 
ture of  this  subject,  I have  been  struck  with  the 
importance  of  the  role  played  by  shock  in  de- 
ciding the  final  issue  of  the  case.  So  forcibly  have 
I been  impressed  with  this  observation  that  I 
believe  we  may  safely  formulate  this  proposi- 
tion, viz:  That  the  greater  the  shock  complicat- 
ing a case  of  surgical  anemia  the  less  the  benefit 
of  infusion  and,  conversely,  the  more  uncompli- 
cated the  anemia  the  greater  the  probabilities  of 
final  and  permanent  recovery  with  infusion.  The 
reasons  for  this  fatal  influence  of  shock  is  readily 
understood  when  we  consider  that  the  most 
striking  manifestation  of  this  condition  is  a 
cardio-vascular  inhibition,  amounting  to  a true 
circulatory  paresis  or  even  complete  paralysis 
in  the  fatal  cases.  Shock  not  only  weakens  the 
cardiac  pump  itself  but  interferes  most  injuri- 
ously with  the  contractility  of  the  peripheral 
vessels,  and  thereby  with  the  compensating 
mechanism  which  plays  so  important  a part  in 
maintaining  a safe  degree  of  vascular  tension  in 
uncomplicated  hemorrhage. 

"Previous  exhaustion  preceding  operative 
procedures  from  acute  or  chronic  suppurative 
and  septic  processes  are  also  certain  to  neutral- 
ize the  permanent  benefits  of  saline  infusion 
when  applied  for  the  relief  of  the  vascular  deple- 
tion consequent  upon  traumatisms. 

CONCLUSIONS 

"1.  In  all  cases  in  which  life  is  threatened  by  cir- 
culatory failure,  from  any  cause,  saline  infu- 
sion may  be  depended  upon  as  a temporary 
restorative. 

2.  Saline  infusion  will  act  as  a permanent  as 
well  as  temporary  restorative  in  all  cases  of 


380  J La  State  Med  Soc  VOL  152  August  2000 


syncope  due  to  simple  and  uncomplicated 
hemorrhage. 

3.  In  all  cases  of  uncontrollable  hemorrhage,  in 
which  the  flow  of  blood  cannot  be  arrested, 
the  beneficial  effect  of  saline  infusion  must 
necessarily  be  ephemeral,  though  even  un- 
der these  circumstances  an  artificial  circula- 
tion of  short  duration  will  be  maintained 
which  may  sustain  life  long  enough  to  be  of 
value. 

4.  Saline  infusion  may  restore  permanently,  as 
well  as  temporarily,  in  cases  in  which  syn- 
cope threatens  life  from  mixed  vascular 
depletion  (hemorrhage)  and  cardio- vascular 
paresis  (shock)  though  the  permanency  of 
the  effect  will  depend  largely  on  the  degree 
of  the  shock.  The  greater  the  shock  the  less 
permanent  the  beneficial  effect. 

5.  In  all  cases  in  which  syncope  is  due  only  to 
cardio-vascular  paresis  or  paralysis  (shock) 
the  effect  of  infusion  is  of  very  doubtful  value 
and  is  almost  always  extremely  ephemeral 
and  rarely  permanent. 

6.  In  all  cases  in  which  syncope  is  due  to  or- 
ganic (nutritive)  as  well  as  dynamic  alter- 
ations in  the  cardio-vascular  apparatus  (e.g., 
exhaustion  from  disease)  the  effect  of  infu- 


sion will  always  be  ephemeral  and  nerve  per- 
manent, though  even  in  these  cases  the  re- 
storative effects  of  infusion  are  worthy  of  re- 
membrance. 

"Having  stated  the  reasons  for  preferring  the 
method  of  saline  infusion  for  that  of  blood  infu- 
sion, and  its  indications,  let  us  now  consider  its 
technical  application. 

"Much  stress  has  been  laid  lately  on  the  su- 
periority of  subcutaneous  infusion  over  the  in- 
travenous method.  My  friend.  Dr  Bayard 
Holmes,  of  Chicago,  has  proven  himself  an  able 
advocate  of  the  subcutaneous  method,  and  there 
is  no  doubt  that  by  availing  ourselves  of  the 
Allen  surgical  pump,  (Figures  1 & 2)  which  he 
recommends  for  the  purpose,  the  injection  of  salt 
water  into  the  subcutaneous  tissue  is  indeed  an 
easy  and  safe  procedure.  But  while  admitting 
that  subcutaneous  infusion  is  an  easier  and  pos- 
sibly safer  procedure  in  the  hands  of  the  inex- 
perienced, I cannot  admit  that  it  is  altogether 
superior,  or  even  equal  in  any  way  to  intrave- 
nous infusion  when  this  is  practiced  by  a care- 
ful operator.  Among  the  now  salient  advantages 
of  the  intravenous  method,  we  must  recognize, 
(1)  absorption;  (2)  it  is  almost  unrestricted  in  its 


J La  State  Med  Soc  VOL  152  August  2000  381 


possibilities,  as  far  as  the  quantity  injected;  (3)  it 
is  comparatively  much  less  painful  than  the  sub- 
cutaneous method;  (4)  it  requires  the  simplest 
and  most  readily  improvised  apparatus  for  its 
performance.  In  our  hospital  practice,  we  have 
generally  used  a very  simple  contrivance,  which 
was  first  mounted  by  Dr  F.W.  Parham  when  as- 
sistant house  surgeon  of  the  institution.  It  con- 
sists simply  of  a large  glass  funnel  to  which  a 
long  drainage  tubing  is  attached,  the  lower  end 
being  inserted  to  an  elongated  metallic  tip  which 
serves  as  a nozzle.  The  flow  in  the  tube  is  con- 
trolled either  by  the  finger  of  an  assistant  or  by 
an  ordinary  wooden  spring  clamp.  The  tip  also 
may  be  improvised  very  successfully  by  utiliz- 
ing the  fine  end  of  a long,  narrow  glass  nozzle, 
such  as  is  found  in  most  fountain  syringes.  Noth- 
ing, therefore,  can  be  easier  to  prepare  than  this 
simplest  of  transfusion  instruments. 

"Now  as  to  the  modus  operandi.  This  is 
equally  simple:  (1)  Disinfect  thoroughly  the 
bend  of  the  elbow  with  soap,  hot  water,  ether 
and  sublimate.  (2)  Expose  a subcutaneous  vein, 
the  most  prominent  in  sight,  either  the  median 
cephalic  or  basilic.  The  exposure  should  be  ef- 
fected by  making  a linear  incision  2 1/2  inches 
parallel  to  the  vein,  so  that  the  cut  can  be  readily 
placed  over  the  vein  by  simply  sliding  the  loose 
skin  over  the  vein.  (3)  Isolate  the  exposed  vein 
by  passing  a grooved  director  under  it.  (4)  Ligate 
the  vein  with  catgut  one  inch  below  (peripheral 
side  of)  the  proposed  puncture.  (5)  Introduce  a 
silk  or  catgut  ligature  under  the  vessel  about  one- 
half  an  inch  above  (cardiac  side  of)  the  proposed 
puncture  and  leave  it  without  tying.  (6)  Open 
the  exposed  vein  by  making  a small  valvular 
nick  in  it  with  sharply-pointed  scissors,  the  an- 
terior vein-wall  being  pinched  up  for  the  pur- 
pose by  a fine-bladed  dissecting  forceps.  (7)  In- 
troduce the  canula  of  the  apparatus,  after  hav- 
ing previously  allowed  the  saline  solution  to 
flow  out  of  the  tip,  so  as  to  secure  the  complete 
exclusion  of  air.  (8)  Tie  the  proximal  end  of  the 
vein  with  the  second  ligature  that  was  ready  for 
the  purpose,  and  include  the  tip  of  the  appara- 
tus in  the  ligature.  (9)  Now  allow  the  liquid  to 
flow. 


"In  the  practice  of  saline  infusion  it  is  also 
important  that  (1)  the  receptacle  destined  to 
contain  the  fluid  be  perfectly  aseptic;  (2)  that  the 
fluid  to  be  injected  be  thoroughly  sterilized;  (3) 
that  the  solution  be  clear  and  heated  to  about 
100°;  1004F.,  (Hayem);  104°F.,  (Esmarch);  104°F., 
(Lorain);  107.6°F.,  (Lotta);  (4)  that  the  solution  of 
salt  in  water  does  not  exceed  7 to  1000  parts;  (5) 
the  fluid  should  not  be  injected  too  rapidly,  the 
velocity  of  the  stream  being  regulated  by  the 
length  of  the  conveying  tube  and  the  height  of 
the  apparatus.  Esmarch  estimates  that  three  fluid 
drachmas  per  second  should  constitute  the  rate 
of  injection;  (6)  the  quantity  injected  should  de- 
pend upon  the  general  effect,  especially  upon 
the  circulation,  guided  by  the  pulse.  The  rule 
should  be  to  inject  for  the  effect;  ie,  the  return  of 
the  normal  arterial  tension  without  special  re- 
gard to  quantity,  fifteen  to  thirty  ounces  being 
usually  the  quantity  required  in  adults  to  pro- 
duce a satisfactory  impression. 

"In  this  connection,  I should  notice  that 
larger  quantities  of  salt  solution  are  required  and 
tolerated  by  the  vascular  system  than  in  blood 
transfusion.  Worm-Muller,  Landois,  Lesser  have 
been  able  to  double,  even  triple  the  total  amount 
of  the  systemic  blood  mass  without  dangerously 
increasing  the  intra-vascular  pressure.  In  these 
cases,  the  injections  have  been  made  very  slowly. 
Ore7,  as  a result  of  numerous  experiments  on 
dogs,  established  the  fact,  based  on  the  circula- 
tion that  the  total  blood  weight  is  equal  to  1-10 
the  total  body  weight,  that  1-20  of  the  total  blood 
(or  1-200  of  body  weight)  could  always  be  trans- 
fused without  any  perceptible  inconvenience. 

"Anyway,  in  saline  solution  there  are  none 
of  the  dangers  encountered  in  the  injections  of 
blood,  and  for  this  reason  the  amount  injected 
should  be  almost  entirely  regulated  by  the  ef- 
fect on  the  pulse.  When  the  pulse  becomes  nearly 
normal  in  frequency  and  volume,  then  stop. 

"No  more  striking  illustration  of  the  recep- 
tive capacity  of  the  vascular  system  with  refer- 
ence to  saline  infusion  could  be  quoted  than  the 
case  recently  reported  by  Dickinson  to  the  Lon- 
don Medical  Society,  February  28,  1890.  (British 
Medical  Journal,  March  8,  1890). 


382  J La  State  Med  Soc  VOL  152  August  2000 


"The  case  was  one  of  diabetic  coma  in  a 
woman  aged  25  years.  Intravenous  infusion  with 
a solution  consisting  of  sodium  chloride,  potas- 
sium chloride,  sodium  sulfate  and  bicarbonate 
dissolved  in  water.  This  was  slowly  injected  by 
means  of  a syringe,  first  into  the  right  arm,  then 
into  the  left  until,  in  the  course  of  one  hour  and 
a half,  106  ounces  had  been  introduced.  About 
ten  minutes  after  the  conclusion  of  the  opera- 
tion, consciousness  began  to  return  and  such 
became  so  complete  that  the  patient  was  able  to 
converse  with  her  friends  and  was  able  to  take 
food  in  a natural  manner. 

"But  she  relapsed  into  drowsiness,  and  the 
next  day  was  as  comatose  as  before  the  opera- 
tion. The  injection  was  now  repeated  into  one  of 
the  veins  of  the  leg,  into  which  the  fluid  was  al- 
lowed to  flow  from  a funnel.  Under  the  opera- 
tion which  required  a little  chloroform,  the 
patient's  condition  appeared  to  improve,  and 
with  this  encouragement  the  injection  was  con- 
tinued until  increasing  fullness  of  the  superfi- 
cial veins  and  some  general  appearance  of  con- 
gestion were  taken  as  indications  to  stop;  there 
was  as  yet  no  return  to  consciousness,  in  the 
hope  of  which,  the  proceeding  had  been  contin- 
ued. It  was  now  found  that  no  less  than  350 
ounces,  or  17  1/2  imperial  pints,  had  passed  in. 
This  was  a much  larger  quantity  than  had  been 
intended,  but  the  process  was  allowed  to  go  on 
under  the  encouragement  which  the  former  at- 
tempt seemed  to  afford,  and  in  the  absence  of 
prohibitive  symptoms  until  the  increasing 
conjestion  was  thus  interpreted.  Three-quarters 
of  an  hour  after  this  second  injection,  conscious- 
ness returned  and  lasted  without  drowsiness  for 
nine  hours,  after  which,  she  became  drowsy,  but 
was  for  the  most  part  sensible;  thirty  hours  after 
which  there  was  a lapse  into  coma,  which  was 
final  and  fatal.  In  this  case,  therefore,  a total  of 
456  ounces  of  saline  solution  were  infused  into 
one  patient  in  the  course  of  about  twenty-four 
hours. 

"This  is  certainly  more  than  the  estimated 
average  total  amount  of  blood  in  the  adult  body 
and  bears  out  thoroughly  the  experimental  evi- 


dence furnished  by  Muller,  Landois  and  Lesser. 

"Finally,  to  conclude  with  the  technique,  I 
will  state  that  the  best  results  have  been  obtained 
in  our  practice  with  extemporized  solutions  of 
common  salt  (about  one  teaspoonful  to  one  pint) 
and  in  view  of  this  experience  it  is  unnecessary 
to  refer  to  the  numerous  and  complicated  for- 
mulae that  have  been  recommended  by  various 
authors,  (eg,  Schmidt's,  Lotta's,  Colson's, 
Beaumetz's,  Jenning's,  Hayem's,  Schwartz's, 
etc.),  anything  more  than  a neutral  solution  of 
common  salt  being  in  all  probability  superflu- 
ous. 

"We  should  also  add  that  at  the  end  of  the 
operation  the  wound  in  the  arm  should  be  ac- 
curately closed  and  dressed  antiseptically.  By  the 
careful  observance  of  these  rules  none  of  the 
cases  in  our  hospital  practice  have  been  followed 
by  the  least  sign  of  phlebitis  or  local  disturbance, 
the  operation  being  so  free  from  complications 
and  operative  sequelae  that  it  may  be  regarded 
as  being  practically  innocuous." 


The  following  is  an  excerpt  from  an  editorial,  which 
appeared  in  the  August  1891  issue  of  the  Journal. 


HOSPITAL  REPORTS  AND  CLINICAL 
NOTES  FROM  CHARITY  HOSPITAL 

Large  Fibro-Lipoma  — Excision  And  Recovery 

"John  Flyatt  was  admitted  to  one  of  my 
wards  on  July  2,  1891.  He  states  he  thinks  he  is 
50  years  old,  but  his  apparent  age  is  60  or  over. 
He  is  hale  and  hearty.  He  presents  himself  to  be 
relieved  of  a tumor,  illustrated  in  an  accompan- 
ying cut,  which  is  a burden  in  the  material  sense 
of  the  word,  and  is  making  his  life  a burden  in 
the  figurative  sense.  This  tumor,  however,  is  only 
mechanically  disagreeable,  as  it  is  entirely  free 
from  pain  and  abnormal  sensibility.  It  interferes 
with  sleep  because  the  patient  cannot  turn  eas- 
ily with  it,  and  cannot  get  on  his  back  at  all.  Vari- 
ous estimates  are  made  as  to  its  weight,  ranging 
all  the  way  from  20  to  50  pounds,  the  writer's 


J La  State  Med  Soc  VOL  152  August  2000  383 


Figure  3.  Photo  of  patient. 


figures  being  25  to  30  pounds  (Figures  3 & 4). 

'The  tumor  is  covered  by  skin  and  by  a little 
hair  at  its  top  where  the  scalp  has  been  en- 
croached upon  by  being  drawn  down.  The  skin 
is  of  normal  (dark)  hue;  its  pores  are  enlarged 
by  the  stretching,  and  a few  good-sized  veins 
can  be  traced  under  it.  The  shape  and  size  of  the 
growth  are  not  unlike  those  of  a medium-sized 
watermelon.  It  is  movable,  being  attached  ap- 
parently to  the  skull  from  just  above  the  occipi- 
tal protuberance  downwards  as  far  as  the  back 
of  the  neck  by  a pedicle  measuring  about  four- 
teen inches  in  circumference.  The  measurement 
from  the  skull  down  over  the  upper  then  the 
under  surface  back  to  the  head  was  twenty-nine 
inches,  while  the  other  circumference  was  about 
twenty-five  inches. 

"The  tumor  is  firm,  evidently  solid,  and 
while  its  surface  is  smooth,  it  turns  out  upon 
palpation  that  is  somewhat  irregular  in  outline 
beneath  the  skin,  and  chiefly  so  as  far  as  density 
is  concerned;  it  is  comparatively  soft  at  some 
points,  harder  at  others,  and  very  hard  at  some, 
especially  at  its  most  dependent  portion. 

"The  tumor  is  carried  by  the  old  man  be- 
tween the  shoulder-blades  and  causes  him  to 
assume  when  erect  the  attitude  of  a man  hold- 
ing a sack  on  his  back  or,  more  correctly,  that  of 
a squaw  carrying  a papoose  on  her  back  in  a 
basket  which  is  suspended  from  her  head.  It  in- 
terferes somewhat  with  locomotion  by  this  time 
although  the  patient  was  able  to  chop  his  own 
firewood  up  to  a comparatively  recent  date.  He 


first  noticed  a lump  on  the  back  of  his  head 
about  25  years  ago,  it  being  then  nearly  the  size 
of  a hen's  egg.  His  account  of  how  he  came  to 
discover  it  is  amusing.  His  brother's  wife  gave 
birth  to  a child  having  a wen  on  the  back  of  its 
head,  where-upon  the  "granny"  declared  that 
some  one  in  the  family  must  be  the  possessor 
of  such  a wen;  a diligent  search  among  the  mem- 
bers of  the  family  led  to  the  discovery  of  the 
tumor  on  our  old  man.  The  tumor  has  grown 
steadily  until  now,  having  reached  the  size 
shown  in  cut,  and  deciding  the  patient  to  part 
with  it. 

"The  slow  growth,  the  absence  of  pain  and 
of  tenderness,  the  size,  the  solidity,  together  with 
the  irregularity  of  density  and  of  subdermal 
outline,  led  me  to  make  the  diagnosis  of  fibro- 
lipoma  and  I decided  to  operate  the  next  morn- 
ing. 

"Operation  — After  the  tumor  and  its  sur- 
roundings had  been  soaped,  scrubbed,  shaved 
and  thoroughly  irrigated  with  a 1 to  2000  solu- 
tion of  sublimate,  the  patient  was  anesthetized; 
chloroform  was  first  administered,  then  the  an- 
esthesia was  continued  by  means  of  ether  so  as 
to  avoid  too  depressing  an  effect.  The  tumor  was 
raised  as  high  as  we  could  for  a few  moments 
to  empty  it  of  blood  as  much  as  possible  and  an 
elastic  band  was  tied  around  the  pedicle  to  con- 
trol the  circulation  during  the  cutting,  as  the  tu- 


Figure  4.  Photo  engraving  in  Journal. 


384  J La  State  Med  Soc  VOL  152  August  2000 


mor  seemed  vascular  and  the  effects  of  great  loss 
of  blood  on  as  old  a man  as  the  patient  were  to 
be  dreaded.  About  two  inches  below  the  elastic 
band,  I made  a circular  incision  through  the  skin 
down  to  the  tumor  itself,  taking  most  of  the  flap, 
however,  from  the  upper  surface  where  the  skin 
seemed  nicer.  As  the  tumor  was  finally  excised, 
the  cut  vessels  were  quickly  caught  and  either 
twisted  or  tied  by  Dr  F.W.  Parham  who,  together 
with  Dr  E.D.  Martin  and  the  student  of  the  ward, 
Mr  Duson,  ably  assisted  me.  The  hemorrhage 
once  controlled,  the  flaps  were  brought  together 
vertically  by  interrupted  silk  sutures,  a drain- 
age tube  was  inserted  from  the  upper  through 
to  the  lower  end  of  the  incision  and  an  antisep- 
tic dressing  of  iodoform  and  of  bichloride  gauze 
was  applied.  The  old  man  awoke  while  the  last 
stitches  were  being  put  in;  he  had  lost  compara- 
tively little  blood  and  scarcely  suffered  from 
shock. 

" After  ablation,  the  tumor  was  found  to 
weigh  twenty-four  pounds,  and  the  diagnosis 
of  fibro-lipoma  was  confirmed. 


"The  patient  sat  up  in  bed  the  day  after  the 
operation;  was  out  of  bed  the  next  day  and  never 
had  any  fever.  The  wound  healed  by  first  inten- 
tion over  the  greater  part  of  its  extent;  the  drain- 
age tube  was  gradually  withdrawn  from  the 
lower  opening  and  at  date  of  writing,  about  two 
weeks  after  the  operation,  he  is  ready  to  return 
home  a happier  and  lighter  man." 


Dr  Colon  has  a plastic  surgery  practice  in 
Metairie,  Louisiana.  He  has  lectured  on  the  history 
of  medicine  at  LSU  School  of  Medicine— New  Orleans, 
and  Tulane  University  School  of  Medicine 
in  New  Orleans,  Louisiana. 


The  author  and  the  Journal  welcome  comments  on 
the  history  of  medicine. 


Adhesive  bandage,  which  plaintiff  alleges 
defendant  pulled  rapidly  from  skin,  violently  tearing  three 
irs  from  plaintiff's  arm,  which  resulted  in  severe  shock, 
trauma,  disfigurement,  chronic  debilitating  pain  and 
permanent  psychological  damage. 


To  protect  your  reputation,  we 
take  every  claim  seriously. 

Even  the  most  absurd  claims  can  be 
damaging  if  they’re  not  handled  properly. 
Which  is  why  the  full  weight  of  our  more 
than  60  years  of  experience  in  medical 
liability  insurance  is  brought  to  bear  on  each 
and  every  claim,  no  matter  how  frivolous  that 
claim  may  appear.  In  fact,  when  appropriate, 
we  have  appealed  cases  all  the  way  to  the 
United  States  Supreme  Court,  at  no 
additional  cost  to  policyholders.  Because  you 
can’t  put  a bandage  on  a damaged  reputation. 


^Stfeul 

Medical  Services 


©2000  St.  Paul  Fire  and  Marine  Insurance  Company 
Coverages  underwritten  by  St.  Paul  Fire  and  Marine  Insurance 
Company  or  another  member  of  The  St.  Paul  Companies 

www.stpaul.com 


J La  State  Med  Soc  VOL  1 52  August  2000  385 


The  Medical  Education  Commission  Report 
at  the  Turn  of  the  New  Millennium  2000 

Perry  Rigby,  MD;  Edward  Foulks,  MD;  Frank  Riddick  Jr,  MD;  Kurt  Braun,  PhD; 

Robert  Daniels,  MD;  Charles  Hilton,  MD 


The  State  of  Louisiana  Medical  Education  Commission  was  formed  by  Act  3 of  the  1997  Louisi- 
ana Legislature.  The  members  are  appointed  by  the  Louisiana  State  University  Health  Sciences 
Center,  Tulane  University  Medical  Center,  and  Alton  Ochsner  Medical  Foundation  and  report  to 
and  advise  the  Department  of  Health  and  Hospitals  (DHH) 

This  summation  from  the  Medical  Education  Committee  is  designed  to  answer  three  ques- 
tions. First,  how  does  the  State  of  Louisiana  compare  nationally  in  the  renewal  of  physician 
supply  and  capability?  Second,  what  are  the  current  status  and  trends  of  graduate  medical  edu- 
cation in  Louisiana?  Third,  what  recommendations  are  proposed  to  continue  and  improve  the 
important  relationship  between  the  State  public  hospitals  and  educational  programs? 

The  State  of  Louisiana  has  participated  proportionately  relative  to  population  in  the  growth 
and  progress  of  medical  education  in  this  last  century  and  compares  favorably  with  other  states 
and  the  nation.  Louisiana  exceeds  national  averages  in  the  increase  of  primary  care  residency 
programs  and  positions  and  in  the  retention  of  trainees  in  practice  sites  in  the  State. 

The  three-year  trends  in  total  number  of  graduate  medical  education  filled  positions  has 
been  consistent  with  only  0.4%  change,  with  primary  care  showing  an  overall  increase  of  9%, 
reflecting  increases  in  Family  Medicine  (56%)  and  Medicine/Pediatrics  (41%). 


The  State  of  Louisiana  Medical  Education 
Commission  (MEC)  was  formed  by  Act 
3 of  the  1997  Louisiana  Legislature.  The 
members  are  appointed  by  the  Louisiana  State 
University  Health  Sciences  Center  (LSUHSC), 
Tulane  University  Medical  Center  (TMC),  and 
Alton  Ochsner  Medical  Foundation  and  report 
to  and  advise  the  Department  of  Health  and 
Hospitals  (DHH).  The  MEC  has  now  issued 
three  consecutive  annual  reports  to  provide  a 


comprehensive  and  detailed  description,  analy- 
sis, and  explanation  of  Graduate  Medical  Edu- 
cation (GME)  in  Louisiana. 

Graduate  Medical  Education  are  post  MD 
and  post  DDS  programs  including  residency  and 
fellowship  training  leading  respectively  to  spe- 
cialty and  sub-specialty  certification.  This  post- 
graduate education  is  also  necessary  for 
credentialing  all  doctors  for  the  practice  of  Medi- 
cine. 


386  J La  State  Med  Soc  VOL  152  August  2000 


Interns,  Residents,  and  Fellows  are  recruited 
by  Academic  Medical  Centers  and  teaching  hos- 
pitals through  a national  matching  process  con- 
ducted by  the  National  Residency  Matching  Pro- 
gram (NRMP)  and  several  specialty  specific 
matches.  These  events  set  in  motion  the  process 
of  annual  renewal  of  physician  supply  in  Loui- 
siana. These  arduous  programs  last  3 to  8 years 
and  follow  4 years  of  medical  school  and  4 years 
of  college.  They  are  rigorous  in  their  educational 
requirements  and  contribute  greatly  to  patient 
care  in  teaching  hospitals. 

This  paper  will  summarize  the  more  detailed 
MEC  report  which  includes  a data  base  on  GME 
size,  status,  number,  distribution,  location,  spe- 
cialty, and  production.  Special  sections  in  the 
original  report  describe  the  match,  the  process 
and  structure,  governmental  relationships,  pri- 
mary care,  finance,  inter-institutional  interrela- 
tionships, supply,  the  Health  Care  Services  Di- 
vision (HCSD)  Hospitals,  each  academic  insti- 
tution, and  recommendations.  This  report  rep- 
resents the  third  in  a yearly  series,  thus  record- 
ing the  trends  for  total  GME  and  for  primary 
care  GME. 

This  MEC  summary  report  answers  three 
questions.  First,  how  does  the  State  of  Louisi- 
ana compare  nationally  in  the  renewal  of  physi- 
cian supply  and  capability?  Second,  what  are 
the  current  status  and  trends  of  GME  in  Louisi- 
ana? Third,  what  recommendations  are  pro- 
posed to  improve  this  important  long-term  en- 
terprise, especially  the  relationship  between  the 
State  public  hospitals  and  educational  pro- 
grams? 

HISTORY 

Medicine  and  Science  have  made  remarkable, 
accelerating,  and  cumulative  advances  over  the 
last  millennium.  The  last  century  especially  has 
witnessed  a profound  change  in  the  growth  and 
progress  of  medical  education  and  its  ultimate 
expression  in  GME.  At  the  beginning  of  the  20th 
century,  key  scientific  discoveries  and  educa- 
tional trends  ignited  the  quest  for  better  health 


care  by  application  of  improvements  in  educa- 
tion and  research.  The  march  of  technology,  the 
Flexner  report,  and  the  formal  establishment  and 
requirement  for  the  postgraduate  education  of 
physicians  set  the  basis  for  quality  and  quantity 
and  for  the  preeminent  role  of  the  United  States 
in  medical  care,  biomedical  research,  and  phy- 
sician education. 

The  State  of  Louisiana  has  participated  in  this 
growth  and  progress  of  medical  education  and 
compares  favorably  with  other  states.  This  en- 
terprise, to  date,  is  a success  conducted  by  the 
public  and  private  academic  medical  centers  and 
teaching  hospitals  with  considerable  state  sup- 
port and  encouragement. 

RESULTS 

The  State  of  Louisiana  meets  the  national  aver- 
age regarding  the  ratio  of  GME  / total  physicians 
(16%),  the  ratio  of  primary  care  physicians /to- 
tal physicians  (37%),  and  the  ratio  of  physicians/ 
100,000  population  (258/100,000).  Louisiana  ex- 
ceeds national  averages  in  the  increase  of  pri- 
mary care  residency  programs  and  positions  and 
in  the  retention  of  trainees  into  practice  sites  in 
the  State. 

The  interesting  and  unique  feature  of  this 
educational  arrangement  in  Louisiana  is  the 
major  role  of  the  State  public  hospitals  in  the 
state-wide  health  care  delivery  system  and  their 
inextricable  link  with  student  and  GME  educa- 
tional programs.  Sixty  percent  of  all  residents 
and  fellows  are  assigned  to  these  public  hospi- 
tals at  any  given  time  and  practically  all  at  some 
time  in  the  course  of  their  educational  programs. 

The  current  status  of  residents  and  fellows 
in  GME  programs,  filled  positions  annually,  is 
exhibited  in  Table  1 by  specialty  and  institution 
for  fiscal  1999,  the  last  full  year  of  data.  Subspe- 
cialty Fellowship  data  are  indented.  Summary 
calculations  are  shown  for  primary  care  and  to- 
tals. See  the  Table  notes  for  explanation.  A pie 
chart  (Figure)  is  included  to  graphically  show 
the  proportion  of  residents  and  fellows  from 
each  institution  at  their  basic  appointment. 


J La  State  Med  Soc  VOL  152  August  2000  387 


Tulane 

27% 


Private 

Base 

713 

40% 


BRG 


TOTAL  = 
1804 
100% 


State  Public 
Base 
LSUHSC 
1091 
60% 


Figure.  The  proportion  of  residents  and  fellows 
based  at  the  institution  of  origin  for  GME 
appointments. 


TRENDS 

The  3-year  trends  in  total  numbers  of  GME  filled 
positions  is  flat,  the  percentage  change  equals 
0.4%.  The  3-year  trend  in  primary  care  GME 
filled  positions,  however,  shows  an  overall  in- 
crease of  9%,  primarily  supported  by  increases 
in  Family  Medicine  (56%)  and  Medicine  / Pedi- 
atrics (41%);  other  relatively  smaller  changes 
take  place  in  proportion,  of  course,  within  indi- 
vidual GME  programs  and  within  and  among 
institutions. 


grams  in  Louisiana,  183/379.  The  seniors  from 
LSUHSC  (244)  were  retained  in  the  State  at  60% 
(142),  and  60%  (87)  of  those  were  in  primary  care; 
the  60%  retention  also  applies  to  those  finishing 
GME  and  to  the  proportion  of  physicians  in 
Louisiana  educated  at  LSUHSC. 

DISCUSSION 

The  future  of  GME  in  Louisiana  appears  to  be 
bright,  rich  in  history  and  accomplishments, 
comparable  in  scope  and  size  nationally.  This 
record  and  its  continuity  and  improvement  in 
the  education  and  renewal  of  physicians  in  Loui- 
siana is  dependent  on  ongoing  institutional  com- 
mitments. The  academic  medical  centers  and 
teaching  hospitals  must  sustain  and  enhance 
recruitment  efforts  for  quality  and  quantity, 
based  on  acknowledged  reputation,  expertise, 
capacity,  and  appropriate  state  support.  Federal 
interventions  in  GME  are  worrisome  and  typi- 
cally result  in  less  funding.  State  support  is  cru- 
cial and  necessary. 

As  is  true  nationally,  the  short-  and  long-term 
maintenance  and  improvement  in  GME  will  re- 
quire more  funds  to  be  competitive.  The  MEC 
key  recommendation  is  to  increase  the  annual 
stipends  yearly  for  residents  and  fellows  to  meet 
or  exceed  the  Southern  Regional  Averages  in 
order  to  recruit  the  highest  quality  future  physi- 
cians for  Louisiana. 


THE  MATCH 

The  success  this  last  year,  1999,  of  the  match  for 
first  and  second  year  GME  positions  in  Louisi- 
ana is  of  special  note.  We  measure  success  on  an 
individual  basis.  The  overall  filled  positions 
(433)  compared  to  those  offered  in  the  match 
(452)  was  96%,  which  compares  very  favorably 
on  a national  basis. 

The  major  academic  medical  centers  and 
teaching  hospitals  did  especially  well,  100%  or 
nearly  so.  Family  Medicine  matched  overall  at 
83%,  57  of  69  positions,  and  had  an  increased 
number  of  positions  each  of  the  last  3 years. 

Forty-eight  percent  of  senior  graduates  from 
Louisiana  medical  schools  entered  GME  pro- 


CONCLUSIONS 

The  State-wide  GME  programs  are  a significant 
and  strategic  opportunity  to  serve  the  health  care 
needs  and  the  education  of  health  professionals 
for  the  citizens  of  Louisiana. 

Table  Notes 

Louisiana  State  University,  Tulane  University, 
Ochsner  Foundation,  Baton  Rouge  General  Hos- 
pital, and  East  Jefferson  Hospital  were  the  five 
institutions  providing  graduate  medical  educa- 
tion in  1998-1999.  The  data  in  the  following  Table 
are  from  these  five  institutions  and  cover  the 
period  of  fiscal  1999  (July  1,  1998  through  June 
30,  1999). 


388  J La  State  Med  Soc  VOL  1 52  August  2000 


Terminology 

Internship  refers  to  the  first  year  of  any  of  the 
various  GME  residency  programs;  all  of  the 
GME  participants  are  referred  to  as  House  Of- 
ficers. 

Resident  is  used  in  this  document  to  refer  to 
a participant  in  a formal  program  of  graduate 
medical  education  leading  to  initial  certification 
in  a specialty  or  to  a participant  in  a program  of 
postgraduate  medical  education  which  is  pre- 
requisite for  entry  into  a program  leading  to  ini- 
tial certification  (transitional  year  programs). 

Fellow  is  used  to  refer  to  a physician  who 
has  completed  the  requirements  of  a program 
leading  to  initial  certification  in  a specialty  and 
who  is  participating  in  a program  of  graduate 
medical  education  in  a subspecialty  of  the  disci- 
pline. Most  of  these  programs  lead  to  certifica- 
tion in  a subspecialty  of  a discipline  (eg,  cardi- 
ology, maternal  and  fetal  medicine)  but  in  some 
instances  the  primary  certifying  body  has  not 
yet  developed  programs  of  certification  in  the 
sub-discipline  (eg,  retinal  disease,  cutaneous 
micro-graphic  surgery). 

METHOD 

The  MEC  method  on  data  collection  annually  is 
to  begin  with  submission  of  GME  filled  positions 
for  the  last  full  year  by  the  academic  medical 
institution.  The  number  of  filled  positions  are 
identified  by  institution,  PGY  level,  specialty 
and/or  subspecialty,  and  assignment  (hospital). 
The  numbers  are  rolled  up  into  summaries  for 
additional  presentation  to  indicate  totals  and 
percentages. 

These  tables  are  cycled  to  each  institution  for 
correction  and  the  MEC  group  to  finally  agree 
on  the  presentations. 

The  MEC  has  included  in  primary  care  data 
the  residents  in  Family  Medicine,  Internal  Medi- 
cine, Pediatrics,  Medicine-Pediatrics,  Ob-Gyn, 
and  Internal  Medicine /Family  Practice. 


Dr  Rigby  is  Director  of  Health  Care  Systems  and 
Professor  of  Medicine  at  Louisiana  State  University  Health 
Sciences  Center,  New  Orleans  & Shreveport,  Louisiana. 

Dr  Foulks  is  Associate  Dean  and  Professor  of  Psychiatry, 
Clinical  Affairs  & Graduate  Medical  Education,  at  Tulane 
University  School  of  Medicine,  New  Orleans,  Louisiana. 

Dr  Riddick  is  Chief  Executive  Officer  at  Alton  Ochsner 
Medical  Foundation,  New  Orleans,  Louisiana. 

Dr  Braun  is  Support  System  Coordinator,  Health  Care 
Services  Division,  at  Louisiana  State  University  Health 
Sciences  Center,  Baton  Rouge,  Louisiana. 

Dr  Daniels  is  Executive  Assistant  to  the  Chancellor  and 
Professor  of  Psychiatry  at  Louisiana  State  University 
Health  Sciences  Center,  New  Orleans,  Louisiana. 

Dr  Hilton  is  Assistant  Dean  for  Academic  Affairs  and 
Director,  Graduate  Medical  Education,  at  Louisiana  State 
University  Health  Sciences  Center, 
New  Orleans,  Louisiana. 


J La  State  Med  Soc  VOL  152  August  2000  389 


Table.  Graduate  Medial  Education  Filled  Positions  by  Specialty  and  Institution  for  Fiscal  1999  State  of  Louisiana 

Louisiana  Total 

LSUHSC  Total 

LSUHSC-N.O. 

LSUHSC-EKL 

LSUHSC-UMC 

LSUHSC-Shreveport 

Tulane 

Ochsner 

Baton  Rouge  Genera 

East  Jefferson 

Anesthesiology 

55.75 

15.00 

3.50 

11.50 

29.42 

11.33 

♦Pain  Management 

0.83 

0.83 

0.83 

Dermatology 

27.00 

16.00 

14.00 

2.00 

11.00 

♦Dermatology  fellow 

1.00 

1.00 

1.00 

Dentistry 

19.28 

19.28 

19.28 

Emergency  medicine 

87.21 

87.21 

51.21 

36.00 

Family  medicine 

151.33 

116.25 

6.00 

10.62 

24.13 

75.83 

8.08 

21.67 

5.0C 

Internal  Medicine 

279.26 

165.25 

59.56 

33.25 

24.02 

48.42 

68.50 

45.51 

♦Allergy,  Immunology 

2.35 

0.93 

0.93 

1.42 

Cardiovascular  disease 

54.16 

21.16 

11.16 

10.00 

15.00 

18.00 

♦Critical  Care 

1.00 

1.00 

1.00 

♦Endocrinology,  diabetes, 
and  metabolism 

8.14 

2.98 

1.98 

1.00 

3.17 

2.00 

♦Gastroenterology 

20.89 

9.81 

4.81 

5.00 

6.08 

5.00 

♦Geriatric  medicine 

3.92 

3.92 

♦Hematology  and  oncology 

11.75 

7.59 

2.50 

5.08 

4.17 

♦Hepatology 

1.07 

1.07 

♦Infectious  disease 

11.59 

4.59 

3.50 

1.08 

5.00 

2.00 

♦Nephrology 

13.88 

8.88 

5.00 

3.88 

5.00 

♦Oncology 

0.08 

0.08 

♦Pulmonary  disease  and 
critical  care 

19.25 

11.25 

6.00 

5.25 

8.00 

♦ Rheumatology 

6.26 

4.93 

2.93 

2.00 

1.33 

Neurology 

21.60 

10.10 

10.10 

11.50 

♦ Neurophysiology 

2.79 

2.79 

2.79 

Neurological  surgery 

14.08 

8.00 

5.00 

3.00 

6.08 

Obstetrics  and  gynecology 

107.95 

59.54 

35.54 

24.00 

32.42 

16.00 

Ophthalmology 

63.29 

37.54 

28.54 

9.00 

16.75 

9.00 

♦Cornea 

2.01 

2.01 

2.01 

♦Glaucoma 

0.72 

0.72 

♦Retina 

3.96 

3.96 

3.96 

Oral  Surgery 

23.90 

23.90 

18.90 

5.00 

Orthopaedic  surgery 

66.93 

34.34 

18.34 

16.00 

22.58 

10.00 

♦Spine 

0.83 

0.83 

0.83 

♦Sports  medicine 

1.92 

1.00 

1.00 

0.92 

Otolaryngology 

35.33 

21.00 

12.00 

9.00 

14.33 

Pathology 

34.13 

21.13 

12.13 

9.00 

12.00 

1.00 

♦Cytopathology 

3.92 

3.92 

1.00 

2.92 

♦Forensic 

1.00 

1.00 

1.00 

Pediatrics 

106.61 

71.70 

50.53 

21.17 

34.92 

♦Allergy,  immunology 

4.50 

3.50 

1.00 

2.50 

1.00 

♦Cardiology 

4.08 

4.08 

♦Genetics 

1.00 

1.00 

390  J La  State  Med  Soc  VOL  1 52  August  2000 


Louisiana  Total 

LSUHSC  Total 

LSUHSC-N.O. 

LSUHSC-EKL 

LSUHSC-UMC 

LSUHSC-Shreveport 

Tulane 

Ochsner 

Baton  Rouge  Genera 

East  Jefferson 

♦ Hematology,  oncology 

3.35 

2.85 

2.85 

0.50 

> ♦Infectious  diseases 

2.83 

1.08 

1.08 

1.75 

; ♦Neonatal-perinatal 

4 

4 

2 

2 

♦Thoracic  Surgery 

0.92 

0.92 

' ♦Pulmonary 

4.58 

4.58 

Physical  medicine  and 
rehabilitation 

17.34 

17.34 

17.34 

♦Musculoskeletal 

2 

2 

2 

Preventive  medicine 

4.17 

4.17 

Psychiatry 

71.66 

37.16 

22.99 

14.17 

34.5 

♦ Forensic 

1 

1 

1 

♦Geriatric 

1 

1 

1 

Psychiatry  - Child  and 
adolescent 

7.48 

4.48 

4.48 

3 

Radiology 

68.03 

33.11 

22.86 

10.25 

14.92 

20 

♦Neuroradiology 

1 

1 

1 

♦Vascular  Interventional 

1.74 

1.74 

1.74 

Surgery 

170.11 

94.11 

58.53 

35.58 

48 

28 

♦Colon  & Rectal 

3 

1 

1 

2 

♦Laparoscopic 

0.5 

0.5 

0.5 

♦Plastic  surgery 

3 

3 

3 

♦Vascular  surgery 

3 

1 

1 

2 

Thoracic  surgery 

3 

1 

2 

Urology 

25.92 

8 

8 

10.17 

7.75 

Transitional  year 

27.75 

9.67 

9.67 

18.08 

Medicine/Pediatrics 

74.75 

50.75 

32 

18.75 

24 

Internal  Medicine/ 
l Emergency  medicine 

7.88 

7.88 

7.88 

Internal  medicine/ 
Family  practice 

9 

9 

Internal  medicine/  Phys. 
medicine  and  rehab. 

8.32 

8.32 

8.32 

Primary  Care  Residents 

728.91 

463.82 

183.63 

43.87 

48.15 

188.17 

159.83 

78.59 

21.67 

5.00 

% Residents  and  Fellows  in 
Primary  Care 

40.41% 

42.49% 

31.12% 

54.93% 

100.00% 

50.40% 

33.10% 

38.76% 

100.00% 

100.00% 

% Residents  in  Primary  Care 

45.87% 

47.36% 

35.18% 

5493.00% 

100.00% 

57.14% 

38.30% 

47.44% 

100.00% 

100.00% 

Total  Residents 

1589.07 

979.40 

522.05 

79.87 

48.15 

329.33 

417.33 

165.67 

21.67 

5.00 

Total  Fellows 

214.81 

112.12 

68.08 

44.04 

65.58 

37.11 

Total  Residents  & Fellows 

1803.89 

1091.52 

590.13 

79.87 

48.15 

373.38 

482.92 

202.78 

21.67 

5.00 

J La  State  Med  Soc  VOL  152  August  2000  391 


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Does  the  Admissions  Committee  Select 
Medical  Students  in  Its  Own  Image? 

Mollie  Wallick,  PhD;  Karl  Cambre,  MS;  Samuel  McClugage,  PhD 


A previous  issue  of  the  Journal  referred  to  a national  study  of  the  Myers-Briggs  Type  Indicator 
(MBTI)  in  which  12  schools  participated.  A comparison  of  our  students'  type  preference  with 
that  of  their  peers  at  the  11  other  schools  revealed  that  only  two  of  the  11  schools  demonstrated 
our  strong  preference  for  the  combination  of  sensing , thinking , and  judging.  We  wondered  if 
our  Admissions  Committee  members,  too,  would  demonstrate  a preference  for  the  same 
combination  of  Myers-Briggs  dimensions.  In  fact,  students'  trait  preferences  matched  those 
of  Admissions  Committee  members  on  all  MBTI  dichotomies,  suggesting  that  the  Committee's 
own  image  may  have  influenced  the  selection  of  medical  students.  A Committee  member's 
awareness  and  appreciation  of  his  own  personality  characteristics  may  be  extremely  helpful 
in  the  admissions  process. 


The  July  1999  issue  of  the  Journal  of  the  Loui- 
siana State  Medical  Society  reported  results 
of  the  Myers-Briggs  Type  Indicator 
(MBTI)  administered  to  1,797  students  at  Loui- 
siana State  University  Health  Sciences  Center 
School  of  Medicine  (LSUHSC-SOM)  in  New 
Orleans  from  1988  through  1998.1  A follow-up 
article  in  the  September  1999  issue  of  the  Jour- 
nal explored  the  association  between  the  per- 
sonality type  and  the  chosen  career  of  1,262  of 
the  same  students  who  completed  their  medi- 
cal undergraduate  studies  by  May  1999.2 

As  documented  in  the  first  article,  the  School 
of  Medicine  in  New  Orleans  participated  in  a 
national  study  which  solicited  type  data  from 


all  US  medical  schools.3  Ultimately,  12  geo- 
graphically diverse  schools,  9 public  and  3 pri- 
vate, contributed  to  a data  base  of  3,987  gradu- 
ates of  the  years  1983  through  1995.  When  we 
compared  our  students'  type  preference  with 
that  of  their  peers  at  the  11  other  participating 
schools,1'3  we  found  that  extraversion  was 
slightly  favored  at  all  12  schools  but,  surpris- 
ingly, only  two  other  schools  demonstrated  our 
strong  preference  for  the  combination  of  sens- 
ing, thinking , and  judging.1 

The  current  study  contributes  further  to  our 
understanding  of  student  type  in  the  SOM  by 
exploring  the  relationship  of  Myers-Briggs  type 
of  Admissions  Committee  members  and  type 


J La  State  Med  Soc  VOL  152  August  2000  393 


of  the  entering  class  of  August  1999.  These  175 
matriculants  were  not  included  in  the  earlier 
studies  but  share  their  SOM  predecessors'  pref- 
erence for  sensing-thinking- judging.  Our  working 
hypothesis  was  that  the  Admissions  Committee 
had  admitted  matriculants  in  its  own  image — 
in  other  words,  that  Committee  members,  too, 
would  demonstrate  a preference  for  the  same 
combination  of  Myers-Briggs  dimensions. 

BACKGROUND 

During  the  past  two  decades,  considerable  lit- 
erature has  been  published  on  the  medical 
school  admission  process,  with  heavy  concen- 
tration on  the  influence  of  the  interview  on  the 
evaluation  of  applicants.410  The  titles  of  two 
1980  journal  articles  articulate  the  dilemma: 
"Medical  School  Admissions  Interview:  Pro  and 
Con"4  and  "The  Admission  Interview:  Doing  It 
to  the  Applicant".5  The  following  year,  a na- 
tional survey  of  US  medical  schools  revealed  that 
99%  of  responding  schools  (87%  response  rate) 
used  interviews  in  evaluating  non-intellectual 
characteristics  of  applicants  and  that  the  inter- 
view, among  selection  factors,  ranked  second  in 
importance  only  to  grade-point  average,  fol- 
lowed by  MCAT  score  and  references.6 

A 1990  study  found  that  interviewers  "are 
often  biased  in  terms  of  ...  an  applicant's  . . . 
similarity  to  the  interviewer"  (italics  added).8  A 
1995  meta-analysis  of  the  literature  on  specialty 
choice  reported  that  interviewers  "unconsciously 
bring  their  own  backgrounds  and  preferences  to  bear 
on  their  perceptions  and  decisions"  (italics  added).11 

A review  of  literature  produced  only  one  1984 
article  from  Utah  School  of  Medicine  on  person- 
ality type  of  Admissions  Committee  members 
and  medical  school  applicants.12  In  contrast  to 
practice  at  LSUHSC-SOM  where  matriculants 
only  are  asked  to  complete  the  MBTI,  all  appli- 
cants at  Utah  were  invited,  but  not  required,  to 
do  so.  Also,  interviews  at  Utah  were  conducted 
by  two-person  teams,  unlike  LSU  where  all  in- 
terviews are  individual,  thereby  obviating  a 
comparison  of  results  with  our  own. 

It  is  of  interest  that  the  Utah  report  opened 

394  J La  State  Med  Soc  VOL  152  August  2000 


with  the  statement,  "the  admissions  process  to 
medical  school  has  been  criticized  since  medi- 
cal schools  opened  their  doors."12  Since  that 
time,  significant  strides  have  been  made  in  de- 
veloping innovative  ways  to  increase  validity  of 
the  interview  in  the  medical  admissions  process. 
Indeed,  in  the  waning  years  of  the  twentieth  cen- 
tury, with  rare  exception,13  the  research  litera- 
ture has  supported  the  continued  use  of  the  ad- 
missions interview. 

The  Admissions  Process  at  LSUHSC-SOM 

Each  of  the  24  Admissions  Committee  members 
at  the  SOM  serves  for  3 years,  with  possible  re- 
appointment; an  orientation  with  staff  is  re- 
quired. The  1998-1999  Committee  that  selected 
the  entering  class  of  August  1999  was  composed 
of  13  members  of  clinical  departments,  most 
from  primary  care  specialties;  5 basic  science 
faculty  members;  2 retired  faculty  members;  1 
alumnus;  and  3 fourth-year  medical  students. 
Of  the  24,  8 were  women. 

Three  Committee  members  interview  appli- 
cants one-on-one  in  the  SOM  Medical  Education 
Building.  Interviews  are  semi-structured,  with 
interviewers  asked  to  evaluate  applicants  on 
such  dimensions  as  self-esteem,  motivation, 
communication  skills,  humanism,  leadership 
potential,  and  support  systems.  The  addition 
of  what  is  learned  in  the  personal  encounter  to 
information  already  in  the  applicant's  file  forms 
the  basis  of  the  impression  an  interviewer  will 
have  of  the  applicant. 

METHOD 

Administration  of  the  MBTI 

As  is  the  custom  at  the  SOM,  all  175  members  of 
the  current  first-year  class  completed  the  MBTI 
either  during  Freshman  Orientation  or  within 
10  days  thereafter.  In  contrast,  repeated  requests 
over  a 3-month  period  were  required  to  gain  the 
cooperation  of  Committee  members.  Not  count- 
ing one  faculty  member  who  left  the  SOM  and 
the  city,  ultimately  22  of  the  remaining  23  mem- 
bers completed  the  self-report  questionnaire. 


Statistical  Analyses 

In  order  to  delineate  differences  in  choice 
between  the  entering  class  of  1999  and  the 
Admissions  Committee  that  selected  them,  we 
constructed  a 2 x 2 chi-square  table  for  each  of 
the  four  Myers-Briggs  dichotomies  (E  vs  1,  S vs 
N,  T vs  F,  / vs  P).  In  addition,  we  performed  t- 
tests  to  determine  differences  in  the  strength  of 
trait  preference  between  students  and  their 
selection  committee.  In  order  to  perform  the  t- 
tests,  we  created  a set  of  preference  continuous 
variables.  We  did  this  by  assigning  a positive 
value  to  the  score  of  one  choice  in  each 
dichotomy  or  a negative  value  to  the  score  of  its 
opposite.  (For  example,  an  individual  with  a 
score  of  E 06  was  assigned  a value  of  E/I  = +06, 
while  one  with  a score  of  112  was  assigned  a 
value  of  E/I  = -12). 

RESULTS 

Table  1 presents  Myers-Briggs  trait  preferences 
of  students  of  the  entering  class  of  1999  and 
members  of  the  respective  Admissions 
Committee.  The  chi-square  analysis  reveals  that 
student  preferences  matched  Admission 
Committee  preferences  in  all  cases.  (We  consider 
the  equal  number  of  E vs  I choices  among 


committee  members  not  in  disagreement  with 
the  predominant  E choice  of  students.) 

Table  2 presents  a comparison  of  the  strength 
of  trait  preferences  between  students  and 
members  of  their  selection  Committee.  Two 
results  of  note  were  found  in  the  t-test  analysis. 
First,  the  mean  strength  on  the  E/I  scale  for 
students  fell  in  the  E range,  while  that  of 
Committee  members  was  in  the  I range; 
however,  the  separation  between  means  was  not 
significant.  A second  finding  was  that,  although 
both  students  and  Committee  members  fell 
within  the  / range  on  the  J/P  scale.  Committee 
members  were  significantly  more  / than  the 
students  they  selected  for  admission. 

DISCUSSION 

The  fact  that  trait  preferences  of  members  of  the 
entering  medical  class  of  August  1999  matched 
preferences  of  members  of  the  Committee  that 
admitted  them  suggests  that  "similarity  to  the 
interviewer"8  may  have  influenced  an 
interviewer's  impression  of  an  applicant  and 
that  an  "interviewer's  preferences"  may  have 
affected  "perceptions  and  decisions".11  We 
emphasize  that  the  relationship  of  findings  of 
these  19908  and  199511  studies  to  the  results  of 
our  own  investigation  is  merely  suggestive. 


Table  1. 


of  Students  and  Admissions  Committee  Members 


Students  (n=175)* 

Committee  (n=22)** 

o 

x2 

p 

N 

% 

N 

% 

E Preference 

98 

(56.0) 

11 

(50.00) 

0.285 

.594 

1 Preference 

77 

(44.0) 

11 

(50.00) 

S Preference 

89 

(50.86) 

13 

(59.09) 

.0531 

.466 

N Preference 

86 

(49.14) 

09 

(40.91) 

: 

T Preference 

97 

(55.43) 

13 

(59.09) 

0.106 

.744 

F Preference 

78 

(44.57) 

09 

(40.91) 

J Preference 

111 

(63.43) 

17 

(77.27) 

1.646 

.200 

P Preference 

64 

(36.57) 

05 

(22.73) 

* Entering  class  of  1999 
** Admissions  Committee  1998-1999 


J La  State  Med  Soc  VOL  152  August  2000  395 


Table  2.  Comparison  of  Preference  Means  of  Students  and  Admissions  Committee  Members 

Students  (n=175)* 

Committee  (n=22)** 

t 

df 

P 

E/I  Preference 

3.89  E 

3.18  1 

-1.130 

195 

.260 

S/N  Preference 

3.25  S 

7.27  S 

0.631 

195 

.529 

T/F  Preference 

4.53  T 

8.36  T 

0.676 

195 

.500 

J/P  Preference 

8.36  J 

21.18  J 

2.007 

195 

.046 

* Entering  class  of  1999 
**  Admissions  Committee  1998-1999 


A limitation  of  the  current  study  is  our 
inability  to  match  individual  interviewers  with 
respective  matriculants.  A second  limitation  is 
that  Myers-Briggs  types  of  Admission 
Committee  members  of  the  other  11  schools13 — 
the  two  in  which  students'  profiles  matched  our 
own  and  the  nine  that  did  not — are  unavailable 
for  comparison. 

A previously  cited  1980  tongue-in-cheek 
essay  on  the  admission  interview  at  'Superlative' 
University  School  of  Medicine5  reports  that  the 
Committee  uses  an  applicant's  written  and 
verbal  comments  "principally  as  evidence  that 
a person  exists  who  corresponds  to  the 
individual  named  on  the  transcript  and  AMCAS 
application.14  Rather  than  considering  the 
interviewers'  personality  preference,  the 
Committee  members  at  Superlative  U were 
asked  to  "be  on  the  lookout  for  deviates  such  as 
men  without  vests  and  applicants  who  show  no 
visible  evidence  of  having  been  shaken  badly 
by  the  interview  experience. 14 

Joking  aside,  medical  schools  that  make  use 
of  the  interview  consider  the  process  a valuable 
component  in  choosing  applicants  who  will  be 
successful  both  in  school  and  in  practice.  It 
should  be  emphasized  that  a consideration  of 
applicants'  psychological  type  is  inappropriate 
in  the  selection  of  future  physicians.  As  stated 
in  1984,  "it  would  be  against  the  accepted  ethical 
standards  of  the  Association  for  Psychological 
Type  to  use  type  as  a criterion  for  admission  or 
rejection."12  However,  a Committee  member's 
awareness  and  appreciation  of  his/her  own  trait 


preferences  may  be  extremely  helpful  in  the 
process. 

The  role  of  personality  type  in  academic 
medicine — and  Myers-Briggs,  in  particular — 
was  recognized  recently  in  MedCAREERS,14  a 
joint  project  initiated  in  1999  by  the  Association 
of  American  Medical  Colleges  and  the  American 
Medical  Association,  with  significant  financial 
support  from  GlaxoWellcome.  MedCAREERS 
comprises  a career  guidance  program  through- 
out the  4 years  of  medical  school,  with  the  task 
of  the  first  year  being  self-assessment:  under- 
standing one's  goals,  values,  strengths,  interests, 
and  personality  characteristics;  in  this  regard,  it 
is  recommended  that  the  MBTI  be  administered 
during  freshman  orientation.  The  linchpin  of 
MedCAREERS  in  the  third  year  is  the  GlaxoWellcome 
Pathway  Evaluation  Program®  for  medical 
specialty  selection.15  An  option  in  the  Pathway 
Program  is  the  incorporation  of  the  relationship 
of  Myers-Briggs  and  its  relationship  to  specialty 
choice.16  Other  potential  uses  of  the  MBTI  in 
academic  medicine  include  educational 
planning,  examination  taking,  and  decision- 
making.1 

Yet  another  more  recent — and  more 
unexpected — appreciation  of  Myers-Briggs 
personality  type  was  reported  at  the  US  Naval 
Academy,  where  officials  are  "making  small 
adjustments  in  their  once-rigid  program  to  help 
students  over  personality  challenges  that  once 
might  have  ended  a brilliant  military  career 
before  it  started."17  As  is  true  at  LSUHSC, 


396  J La  State  Med  Soc  VOL  152  August  2000 


personality  typing  at  the  Academy  "will  never 
be  a consideration  in  admissions  or  promotions 
decisions — there  is  no  personality  type  . . . that 
does  not  belong." 

CONCLUSIONS 

In  the  case  of  the  LSUHSC-SOM  entering  class 
of  1999,  students'  Myers-Briggs  trait  preferences 
matched  those  of  Admission  Committee 
members  on  all  MBTI  dichotomies.  This  does 
indeed  suggest  that  the  Committee's  own  image 
may  have  influenced  the  selection  of  medical 
students.  Ethical  considerations  demand  that 
psychological  type  not  be  used  as  a criterion  for 
selection  or  rejection.  However,  self-knowledge 
on  the  part  of  the  interviewer  is  invaluable  in 
obviating  an  unfair  evaluation  of  the  abilities  of 
a potential  member  of  the  medical  community 
whose  life  view  differs  from  the  interviewer's 
own. 

REFERENCES 

1.  Wallick  MM,  Cambre  KM.  Personality  types  in 
academic  medicine.  J La  State  Med  Soc  1999;151:378- 
382. 

2.  Wallick,  MM,  Cambre  KM,  Randall  HM.  Personality 
type  and  medical  specialty  choice.  / La  State  Med 
Soc  1999;151:463-469. 

3.  Stilwell  NA,  Wallick  MM,  Thai  SE,  et  al.  Myers- 
Briggs  type  and  medical  specialty  choice:  a new  look 
at  an  old  question.  Teaching  and  Learning  in  Medicine: 
An  International  Journal.  2000;12:14-20. 

4.  Fruen  MA.  Medical  school  admissions  interview: 
pro  and  con.  J Med  Ed  1980;55:630-631. 

5.  Rose  JC.  The  admission  interview — doing  it  to  the 
applicant.  Pharos  1980;43:13-14. 

6.  Puryear  JB,  Lewis  LA.  Description  of  the  interview 
process  in  selecting  students  for  admission  to  US 
medical  schools.  J Med  Ed  1981;56:881-885. 

7.  Elam  CL,  Andrykowski  MA.  Admission  interview 
ratings:  relationship  to  applicant  academic  and 
demographic  variables  and  interviewer  character- 
istics. Acad  Med  1991;66:S13-S15. 

8.  Edwards  JC,  Johnson  EK,  Molidor  JB.  The  interview 
in  the  admission  process.  Acad  Med  1990;65:167-177. 

9.  Bullimore  DW.  Selection  interviewing  for  medical 
school  admission.  Med  Educ  1992;26:347-349. 

10.  Nowacek  GA,  Bailey  BA,  Sturgill  BC.  Influence  of 
the  interview  on  the  evaluation  of  applicants  to 
medical  school.  Acad  Med  1996;71:1093-1095. 


11 . Bland  CJ,  Meurer  LN,  Maldonado  G.  Determinants 
of  primary  care  specialty  choice:  a non-statistical 
meta-analysis  of  the  literature.  Acad  Med 
1995;70:620-641. 

12.  Harris  DL,  Coleman  ML,  Barney  DP.  Personality 
types  of  admission  committee  members  and 
student  applicants,  as  measured  by  the  Myers- 
Briggs  Type  Indicator.  J Psycholog  Type  1984;8:36- 
41. 

13.  Taylor  TC.  The  interview:  one  more  life?  Acad 
Med  1990;65:177-178. 

14.  MedCAREERS:http:  / / www.aamc.org/  medcareers. 

15.  Sogol  EM.  Students'  pathway  to  groups.  Group 
PractJ  1990;39:61-65. 

16.  Wallick  MM.  Reflections  on  the  Glaxo  Program: 
twenty-some-odd  workshops  and  still  counting. 
Viewpoint  1991;1:3. 

17.  Argetsinger  A.  Test  of  character:  US  Naval  Acad- 
emy analyzes  personality  types  to  slow  dropout 
rate.  The  Washington  Post  1999;October  25:B1,  B4. 


Dr  Wallick  is  Emeritus  Professor  of  Psychiatry  at 
Louisiana  State  University  Health  Sciences  Center 
School  of  Medicine  in  New  Orleans,  Louisiana. 

Mr  Cambre  is  Manager  of  Scientific  Programming  in 
Computer  Services  at  Louisiana  State  University 
Health  Sciences  Center  in  New  Orleans,  Louisiana. 

Dr  McClugage  is  Assistant  Dean  for  Admissions  at 
Louisiana  State  University  Health  Sciences  Center 
School  of  Medicine  in  New  Orleans,  Louisiana. 


J La  State  Med  Soc  VOL  152  August  2000  397 


Tuberculosis  Screening,  Referral,  and 
Treatment  in  an  Inner  City  Homeless  Shelter 

in  Orleans  Parish 

Gerald  Falchook,  BA;  Chris  Gaffga,  BA;  Sandra  Eve,  RN-C;  Juzar  Ali,  MD 


Tuberculosis  screening  and  preventive  therapy  among  the  homeless  has  been  a challenge  be- 
cause of  the  lack  of  coordinated  follow-up.  Homeless  persons  at  a homeless  shelter  in  inner 
city  New  Orleans  were  screened  for  tuberculosis  infection  and  referred  for  follow-up  evalua- 
tion and  preventive  therapy.  Fifty-two  percent  of  the  104  persons  screened  completed  the  ini- 
tial evaluation.  Twenty-two  percent  of  these  patients  had  latent  tuberculosis  infection.  Forty- 
two  percent  of  infected  patients  completed  the  referral  and  follow-up  process.  Patients  dur- 
ing the  second  3 months  of  the  program  were  twice  as  likely  to  complete  the  initial  evalua- 
tion, the  referral,  and  the  follow-up  process  as  were  patients  during  the  first  3 months  due  to 
enhanced  awareness  and  increased  educational  intervention.  A competent  referral  system  for 
homeless  persons  may  be  achieved  by  implementing  a single-clinic,  on-site  tuberculosis  screen- 
ing and  follow-up  system  with  the  active  participation  and  coordination  of  state  agencies,  the 
medical  community,  and  organizations  which  operate  homeless  facilities. 


Congregate  settings  such  as  homeless 
shelters  provide  one  of  the  major  reser- 
voirs of  tuberculosis  infection  in  the 
United  States.1  Despite  the  steady  decline  in  the 
incidence  of  tuberculosis  since  1992,  tubercu- 
losis infection  persists  among  the  homeless  and 
the  inner  city  poor  and  remains  a public  health 
problem  in  Louisiana  and  across  the  United 
States.2  The  homeless  represent  one  of  the  high- 
est risk  groups  for  contracting  TB.  Homeless 
persons  are  more  likely  to  become  infected  than 
other  patient  groups  because  of  diminished  im- 
munity from  malnutrition,  crowded  sleeping 
areas  with  poor  ventilation,  delayed  access  to 
medical  care,  mental  illness,  drug  abuse,  alco- 
holism, and  co-infection  with  HIV.  In  addition, 

398  J La  State  Med  Soc  VOL  152  August  2000 


homeless  persons  with  active  tuberculosis  are 
usually  more  infectious  than  patients  with  a 
higher  financial  status.3 

One  single  active  case  of  tuberculosis  can  in- 
fect approximately  15-20  persons  per  year,  indi- 
cating that  active  tuberculosis  represents  a sig- 
nificant health  risk  to  the  community.  Persons 
at  the  highest  risk  of  becoming  infected  are  close 
contacts,  including  family  members,  friends,  co- 
workers, roommates,  or  other  co-inhabitants 
such  as  those  found  at  homeless  shelters.  The 
infection  rate  for  contacts  of  infectious  TB  pa- 
tients is  estimated  to  be  about  21%  to  23%.  Other 
studies  have  demonstrated  an  infection  rate  as 
high  as  30%  for  close  contacts  of  active  TB  pa- 
tients. Of  those  persons  who  do  become  infected. 


about  10%  will  develop  active  TB  disease  at  some 
point  in  their  lives,  but  the  risk  is  significantly 
higher  for  persons  who  are  immunosuppressed, 
especially  those  with  HIV  infection.1 

Residents  of  Louisiana,  especially  persons 
who  live  in  the  New  Orleans  metropolitan  area, 
are  at  risk  for  tuberculosis  infection.  In  1998, 
there  were  380  active  cases  of  tuberculosis  in 
Louisiana.  The  case  rate  in  1998  in  Louisiana  was 
8.7  per  100,000  persons,  which  is  slightly  higher 
than  the  national  average  of  7.4  per  100,000. 
However,  the  case  rate  in  the  New  Orleans  area 
is  much  higher  at  13.5  per  100,000,  and  over  one- 
third  (37%)  of  all  cases  in  the  state  of  Louisiana 
in  1998  were  in  the  New  Orleans  area.  The  case 
rate  in  Orleans  Parish  in  1998  was  17.9  per 
100,000.  In  Orleans  Parish,  there  were  86  cases 
of  active  tuberculosis,  representing  23%  of  all 
cases  of  tuberculosis  in  Louisiana  in  1998.2 

From  a national  perspective,  the  overall  in- 
cidence of  active  TB  and  the  prevalence  of  la- 
tent tuberculosis  among  the  homeless  are  un- 
known. However,  based  on  screening  at  selected 
clinics  and  shelters,  the  prevalence  of  clinically 
active  disease,  ie,  active  infectious  tuberculosis 
disease,  ranges  from  1.6%  to  6.8%  and  the  preva- 
lence of  latent  TB  infection  ranges  from  18%  to 
51%. 4 

Tuberculosis  screening  and  preventive 
therapy  among  the  homeless  has  been  a signifi- 
cant challenge  to  the  medical  community  be- 
cause of  the  lack  of  coordinated  follow-up,  re- 
ferral, and  treatment  following  the  screening 
process.  In  the  past,  tuberculin  skin  test  screen- 
ing and  isoniazid  preventive  therapy  programs 
among  homeless  persons  have  been  generally 
ineffective  because  of  poor  patient  adherence  to 
follow-up  visits  and  treatment  regimens.  As  a 
result,  routine  tuberculin  screening  of  asymp- 
tomatic homeless  persons  for  TB  had  in  the  past 
not  been  found  to  be  an  efficient  way  to  identify 
new  active  TB  cases.4 

METHODS 

Homeless  persons  residing  at  a homeless  shel- 
ter in  an  inner  city  area  of  New  Orleans  were 


screened  for  tuberculosis  infection  using  tuber- 
culin skin  testing  and  a questionnaire.  Skin  test 
positive  persons  were  referred  to  the  Wetmore 
Tuberculosis  Clinic  and  the  LSU  Tuberculosis 
Clinic  of  the  Medical  Center  of  Louisiana  at  New 
Orleans  for  follow-up  evaluation  and  preven- 
tive therapy. 

Screening  was  performed  at  the  New  Orleans 
Mission  homeless  shelter,  a facility  that  serves 
the  inner  city  poor  of  New  Orleans,  Louisiana. 
Tuberculosis  screening  services  were  provided 
three  times  a week  at  the  homeless  shelter,  and 
patient  data  were  collected  prospectively  over  a 
period  of  6 months,  from  October  31,  1998  until 
May  8,  1999.  Tuberculosis  screening  services 
were  provided  on  Saturdays  at  the  free  week- 
end clinic  operated  by  volunteer  medical  stu- 
dents from  Louisiana  State  University  School  of 
Medicine-New  Orleans,  under  the  supervision 
of  volunteer  faculty  and  physicians  in  the  com- 
munity. In  addition,  nurse  practitioners  from 
Daughters  of  Charity  of  New  Orleans  volun- 
teered to  provide  their  services  on  Mondays  and 
Thursdays  at  the  homeless  shelter  to  both  ad- 
minister and  evaluate  tuberculosis  skin  tests. 

Patients  with  no  prior  history  of  a positive 
tuberculosis  skin  test  received  the  Mantoux  tu- 
berculin skin  test.  The  Mantoux  test  consisted 
of  5 units  of  purified  protein  derivative  (PPD) 
administered  as  an  intradermal  injection  of  0.1 
cc  of  tuberculin.  Patients  were  educated  about 
the  importance  of  tuberculosis  screening,  the 
risks  of  not  being  tested,  and  the  risks  of  not 
having  their  skin  test  evaluated.  They  received 
a 15-minute  problem-based  education  session 
about  tuberculosis  and  were  then  asked  to  re- 
turn to  have  the  skin  test  evaluated  at  the  ap- 
propriate clinic  time  48-72  hours  later.  Clinic  staff 
provided  patients  with  a written  reminder  of  the 
day  and  time  that  they  should  return  to  the  clinic. 

A skin  test  with  at  least  5 mm  of  induration 
evaluated  48-72  hours  after  placement  was  con- 
sidered to  be  a positive  test.  Patients  who  re- 
turned with  a positive  skin  test  were  then  re- 
ferred to  Wetmore  Tuberculosis  Clinic  and  the 
LSU  Tuberculosis  Clinic  of  the  Medical  Center 
of  Louisiana  at  New  Orleans  for  further  evalua- 


J La  State  Med  Soc  VOL  152  August  2000  399 


tion.  Clinic  staff  educated  patients  about  the 
importance  of  receiving  follow-up  care  at  the 
Wetmore/LSU  clinic  and  the  risks  of  not  seek- 
ing further  medical  assistance.  Patients  received 
written  instructions  as  to  the  location  of  the 
Wetmore/LSU  Clinic  and  were  questioned 
about  their  access  to  transportation  necessary  for 
traveling  to  the  Wetmore  / LSU  Clinic,  which  was 
located  at  a distance  of  one  mile  away.  The  rel- 
evant patient  information  was  faxed  to  the 
Wetmore/LSU  clinic,  and  patients  were  in- 
formed of  the  open  "walk-in"  policy  at  the 
Wetmore/LSU  Clinic,  ie,  patients  were  informed 
that  they  would  not  need  an  appointment  to  be 
seen  at  the  Wetmore/LSU  Clinic.  Prior  arrange- 
ments had  been  made  so  that  any  patient  tested 
at  the  homeless  shelter  could  be  referred  to  the 
Wetmore/LSU  Clinic  without  an  appointment 
or  any  prior  notification. 

Patients  who  returned  with  a negative  skin 
test,  ie,  less  than  5 mm  of  induration  evaluated 
48-72  hours  after  placement,  were  encouraged 
to  return  in  1 week  for  a repeat  booster  test.  Clinic 
staff  informed  patients  that  an  initial  negative 
skin  test  can  be  falsely  negative,  and  thus  a re- 
peat booster  skin  test  ("2-step  test")  1 to  3 weeks 
following  the  first  Mantoux  test  was  recom- 


mended for  homeless  persons  in  high  prevalence 
areas. 

RESULTS 

Table  1 demonstrates  the  results  of  the  tubercu- 
losis screening  and  follow-up  process  during  the 
6-month  duration  of  the  study.  Of  the  104  per- 
sons screened,  54  (51.9%)  completed  the  initial 
evaluation  (Table  1:1.2).  The  return  rate  for  tu- 
berculosis screening  among  inner  city  homeless 
populations  may  vary  according  to  the  group 
examined  and  the  setting  in  which  screening  is 
performed  and  ranges  from  35%  to  65%.5  6 

Out  of  the  54  patients  who  returned  to  have 
their  skin  tests  read,  12  (22.2%)  demonstrated  a 
positive  PPD  (Table  1:1.3).  The  42  patients  who 
had  a negative  PPD  were  either  HIV  negative 
by  history  or  their  status  was  unknown.  The  na- 
tionwide prevalence  of  latent  TB  infection 
among  the  homeless  varies  by  location  and  sub- 
population and  is  in  the  range  of  18%  to  51%.4 
The  remaining  data  in  Table  1 will  be  discussed 
subsequently.  Table  2 reveals  relevant  demo- 
graphic data  of  the  12  persons  identified  with 
latent  tuberculosis  infection. 

The  Figure  shows  that  41  out  of  67  (61.2%) 
patients  during  the  second  3 months  of  the  pro- 


Table  1.  Results  of  Tuberculosis  Screening  and  Follow-up  in  an  Inner  City  Homeless  Shelter 

1.1 

# PPDs  administered 

104 

1.2 

# of  patients  who  returned  to  have  PPD  evaluated 

54  (51.9%) 

1.3 

# of  patients  with  latent  tuberculosis  infection 
(ie,  # of  PPDs  with  induration  of  >5  mm  ) 

12  (22.2%) 

1.4 

# of  patients  with  (+)  PPD  who  completed  referral  to 
the  LSU/Wetmore  TB  clinic  for  further  evaluation 

5(41.7%) 

1.5 

# of  patients  who  were  started  on  chemoprophylactic 
treatment 

3 (60%) 

1.6 

# of  patients  who  were  evaluated  but  were  not 
treated  because  they  did  not  qualify  as  candidates 
for  prophylactic  treatment 

2 (40%) 

400  J La  State  Med  Soc  VOL  152  August  2000 


70 


60 

50 

40 

30 

20 

10 

0 


Number  of 
PPD’s  Placed 


Number 

Evaluated 


Number  Number  Completed 
Positive  Referral  Process 


Weeks  1-14 
Weeks  15-27 


. -j 
■i 


; J 


Figure.  Improvement  in  a Tuberculosis  Screening  Program  Over  a 27-Week  Trial  Period 


gram  completed  their  initial  evaluation  and  re- 
turned for  PPD  reading.  This  return  rate  is  com- 
pared to  13  out  of  35  (35.1%)  in  the  first  3 months. 
The  significance  of  this  finding  will  be  expanded 
upon  in  the  discussion  section. 

Six  patients  received  a repeat  booster  skin 
test  ("2-step  test")  1 to  3 weeks  after  a previous 
initial  negative  skin  test.  Of  the  six  persons  re- 
ceiving the  repeat  test,  four  returned  to  have  the 
test  evaluated,  and  all  four  had  a negative  test, 
therefore  not  requiring  follow-up. 

DISCUSSION 

One  of  the  central  characteristics  of  this  project 
was  the  education  of  the  patient:  education  about 
tuberculosis,  its  transmission,  the  signs  and 
symptoms  of  an  active  infection,  and  the  reasons 
for  tuberculosis  screening.  We  put  forth  the  hy- 


pothesis that  patients  who  are  educated  are  more 
likely  to  return  to  have  the  skin  test  examined 
and  to  seek  follow-up  treatment  if  needed.  We 
also  hypothesized  that  if  a competent  referral 
system  is  outlined,  this  transient  population 
would  obtain  appropriate  follow-up  following 
the  screening  procedures. 

Tuberculosis  screening  and  prevention  of 
active  disease  among  the  homeless  historically 
has  been  very  difficult  for  a number  of  reasons, 
including  (1)  the  transient  nature  of  the  home- 
less population,  (2)  the  poor  compliance  with 
screening  and  follow-up  procedures,  and  (3)  the 
lack  of  education,  ie,  little  knowledge  about  tu- 
berculosis, its  transmission,  or  the  clinical  course 
of  tuberculosis. 

Temporal  analysis  of  the  results  reveals  that 
during  the  last  3 months  of  the  program,  the 
number  of  residents  seeking  tuberculosis  skin 


J La  State  Med  Soc  VOL  152  August  2000  401 


Table  2.  Demographics  of  Patients  Identified  with  Latent  Tuberculosis  Infection 

(n  = 12) 

Range  of  age 

31-50  years 

Range  of  size  of  the  PPDs 

5-20  mm 

Race 

10/12  African  American 
2/12  Other 

Gender 

12/12  Male 

Range  of  education 

9th  grade  to  3 years  of  college 

Previous  prison  history 

3/12 

Tobacco  use 

7/12 

HIV  status  negative  by  history 

11  / 12 

HIV  status  unknown 

1 / 12 

tests  nearly  doubled  and  the  return  rate  for  com- 
pleting the  initial  screening  process  also 
doubled.  This  increase  may  be  attributed  to  ef- 
forts to  arouse  interest  about  tuberculosis  screen- 
ing among  this  population.  As  the  program 
evolved,  the  residents  and  staff  of  the  shelter 
became  more  aware  of  the  tuberculosis  screen- 
ing services.  The  educational  interventions  of 
this  study  encouraged  members  of  the  shelter 
to  become  interested  in  learning  about  the  trans- 
mission of  tuberculosis  and  the  importance  of 
being  screened  for  tuberculosis. 

Our  program  relied  upon  the  dedication  of 
volunteers  willing  to  donate  a few  hours  of  their 
time  each  month.  These  volunteers  were  medi- 
cal students,  physicians,  nurses,  nurse  practitio- 
ners, the  staff  members  of  the  homeless  shelter, 
and  other  members  of  the  medical  community. 

We  found  that  the  patients  we  were  serving, 
ie,  the  homeless  and  inner  city  poor,  were  inter- 
ested in  and  eager  to  receive  the  services  we  pro- 
vided for  them.  The  very  presence  of  our  tuber- 


culosis screening  program  at  the  homeless  shel- 
ter increased  this  population's  awareness  of  tu- 
berculosis. Our  program  filled  a gap  in  services 
needed  in  this  setting.  We  were  able  to  educate 
them  about  tuberculosis,  its  transmission,  the 
signs  and  symptoms  of  an  active  infection,  and 
the  reasons  for  tuberculosis  screening.  As  the 
program  developed  and  as  community  knowl- 
edge about  tuberculosis  increased,  we  observed 
a progressive  increase  in  return  rates  and  fol- 
low-up rates  throughout  the  duration  of  the 
study. 

The  impact  of  education  on  tuberculosis 
screening  return  rates  has  been  evaluated  in 
other  high-risk  tuberculosis  groups.  Screening 
for  tuberculosis  at  an  urban  HIV  clinic  in  Balti- 
more revealed  improvement  of  return  rates 
when  education  was  added  in  addition  to  re- 
deemable food  voucher  incentives.  Return  rates 
for  PPD  reading  were  96  (35%)  of  272  for  the 
control  group.  111  (48%)  of  229  for  the  food 
voucher  group,  and  96  (61%)  of  158  for  the  corn- 


402  J La  State  Med  Soc  VOL  1 52  August  2000 


bined  food  voucher  and  patient  education 
group.5  Our  study,  which  relied  upon  educa- 
tional interventions  alone,  achieved  a similar 
return  rate  of  41  (61.2%)  out  of  67  during  the  sec- 
ond 3 months  of  the  study. 

Other  studies  have  attempted  to  estimate  the 
epidemiology  of  tuberculosis  in  regional  popu- 
lations. A study  performed  in  a large  public  hos- 
pital in  New  York  City  attempted  to  determine 
the  prevalence  of  tuberculosis  infection  in  a co- 
hort of  indigent  persons  in  New  York.  Of  the  651 
persons  screened,  591  (91%)  completed  the  ini- 
tial evaluation  of  having  the  skin  test  read.  The 
prevalence  of  latent  infection  (positive  skin  test) 
was  45%. 7 However,  this  New  York  City  study 
was  not  limited  to  homeless  persons. 

As  mentioned  previously,  a major  problem 
of  tuberculosis  screening  among  the  homeless 
historically  has  been  the  failure  of  skin  test  posi- 
tive patients  to  receive  medical  attention  after 
diagnosis  of  the  latent  tuberculosis  infection 
(positive  skin  test).  Sometimes  the  patient  is 
unable  or  unwilling  to  seek  or  receive  medical 
treatment  after  being  referred  appropriately  by 
the  health  care  worker.  In  many  cases,  the  home- 
less patient  does  not  fully  appreciate  the  nature 
of  tuberculosis  and  the  potential  danger  of  not 
seeking  further  evaluation  or  treatment. 

Patient  education  is  potentially  the  most 
valuable  tool  in  TB  screening  among  the  home- 
less. Our  medical  staff  involved  in  the  screening 
process  made  significant  efforts  to  educate  the 
patients.  The  CDC  recommends  that  educational 
materials  should  be  developed  for  shelter  clients, 
shelter  employees,  and  volunteers.4  This  mate- 
rial should  address  the  mode  of  spread,  the  com- 
mon signs  and  symptoms,  and  methods  for  treat- 
ment and  prevention.  Information  on  local  re- 
sources for  TB  care  should  be  made  available  to 
shelter  staff  and  guests. 

Despite  the  many  obstacles,  tuberculosis 
screening  and  referral  among  the  homeless  can 
be  effective  when  undertaken  with  several  sup- 
portive measures.  The  screening  program 
should  be  located  "on-site",  ie,  the  screening  pro- 
cedures are  performed  on  the  premises  of  the 
homeless  shelter.  The  patient  should  not  be  re- 


quired to  travel  any  appreciable  distance  to  ac- 
cess the  tuberculosis  screening  services.  On-site 
screening  facilitates  the  role  of  the  homeless 
shelter's  volunteers  and  administrators  in  en- 
couraging residents  to  complete  the  screening 
and  referral  process. 

Establishment  of  minimal  continuity  of  care 
at  a homeless  facility  may  aid  the  success  of  a 
screening  and  referral  program.  Tuberculosis 
screening  among  the  homeless  may  be  more  ef- 
fective if  tuberculosis  screening  is  incorporated 
into  a pre-existing,  on-site  program  of  health  care 
services.  Our  screening  program  was  begun 
within  the  context  of  a pre-existing,  free,  on-site 
weekend  clinic,  which  is  operated  by  volunteer 
medical  students  and  community  physicians. 
Screening  may  be  more  effective  if  the  residents 
of  the  shelter  develop  a relationship  with  con- 
tinuous, on-site  health  care  services.  If  the  local 
homeless  community  were  to  build  familiarity 
with  the  medical  staff/ volunteers  of  the  on-site 
medical  program,  compliance  with  the  screen- 
ing process  may  increase. 

Analysis  of  the  referral  completion  rate  in- 
dicates discontinuous  patient  follow-up  between 
the  screening  site  and  the  referral  site.  Five 
(41.7%)  out  of  the  12  patients  with  a positive  PPD 
completed  the  referral  and  evaluation  process. 
Despite  establishing  and  implementing  a flex- 
ible, accomodating,  and  user-friendly  system  for 
referrral  to  the  Wetmore/LSU  TB  clinic,  the  rate 
of  follow-up  on  referral  in  this  study  was  less 
than  50%.  This  may  be  secondary  to  the  tran- 
sient nature  of  this  homeless  population,  or  it 
may  be  due  to  the  inevitable  result  of  a two-clinic 
screening  and  referral  arrangement.  The  absence 
of  a single-clinic  operation  may  have  been  re- 
sponsible for  the  limited  follow-up  rate. 

CONCLUSIONS 

The  model  presented  in  this  program  suggests 
that  a competent  referral  system  for  homeless 
persons  may  be  achieved  by  implementing  an 
on-site  tuberculosis  screening  and  referral  sys- 
tem with  the  active  participation  and  coordina- 
tion of  state  public  health  agencies,  the  medical 


J La  State  Med  Soc  VOL  152  August  2000  403 


community,  service  organizations,  and  commu- 
nity organizations  which  operate  homeless  fa- 
cilities. 

This  study  reaffirms  other  data  suggesting 
that  when  educational  interventions  are  used  for 
PPD  screening,  the  return  rate  for  the  comple- 
tion of  this  process  increases,  even  in  a home- 
less population. 

In  our  model,  the  PPD  screening  was  per- 
formed at  the  homeless  clinic,  whereas  the  re- 
ferral and  treatment  evaluation  was  completed 
at  the  Wentmore  / LSU  TB  clinic.  This  process  did 
not  adequately  meet  the  needs  of  this  homeless 
population.  Despite  the  fact  that  the  referral  sys- 
tem utilized  was  accommodating  and  user- 
friendly,  the  rate  of  follow-up  on  referral  in  this 
study  was  less  than  50%.  Therefore,  we  suggest 
that  both  the  initial  screening  and  the  follow-up 
evaluation  for  prophylaxis  in  the  homeless 
population  should  be  conducted  at  a single,  on- 
site clinic  located  at  their  respective  homeless 
shelters.  We  invite  the  state  public  health  agen- 
cies to  explore  this  possibility. 

ACKNOWLEDGMENTS 

The  authors  would  like  to  thank  the  following 
persons  for  volunteering  their  time  and  their 
services  that  made  this  service  project  possible: 

• James  M.  Deshotels,  Nurse  Practitioner, 
Project  Director  for  the  Integrated  Mobile 
Assessment  and  Treatment  Team 

• The  staff  and  administrators  of  the  New  Or- 
leans Mission  homeless  shelter 

• The  medical  students  of  Louisiana  State 
University  School  of  Medicine  and  the  fac- 
ulty and  community  physicians  who  volun- 
teer at  the  homeless  shelter's  clinic 

• The  staff  of  the  Wetmore/LSU  TB  Clinics 

• Andrea  Garaudy  and  Gerard  Ballanco,  3rd- 
year  medical  students  at  LSU  School  of  Medi- 
cine, New  Orleans,  Louisiana. 

REFERENCES 

1.  Centers  for  Disease  Control  and  Prevention.  Core 
Curriculum  on  Tuberculosis.  3rd  edition.  1994:5-6. 


2.  George  RB,  Farley  TA.  DeGraw  CF,  et  al.  Tubercu- 
losis in  Louisiana:  an  update.  / La  State  Med  Soc 
1998;150:587-595. 

3.  Asch  S,  Leake  B,  Knowles  L,  et  al.  Tuberculosis  in 
homeless  patients:  potential  for  case  finding  in  pub- 
lic emergency  departments.  Ann  Emerg  Med 
1998;32:144-147. 

4.  CDC.  Prevention  and  control  of  tuberculosis  among 
homeless  persons  - recommendations  of  the  advi- 
sory council  for  the  elimination  of  tuberculosis. 
MMWR  1992;  41(RR-5). 

5.  Chaisson  RE,  Keruly  JC,  McAvinue  S,  et  al.  Moore 
RD.  Effects  of  an  incentive  and  education  program 
on  return  rates  for  PPD  test  reading  in  patients  with 
HIV  infection.  JAIDS  1996;11:455-459. 

6.  Bock  NN,  Metzger  BS.  Tapia  JR,  et  al.  A tuberculin 
screening  and  isoniazid  preventive  therapy  pro- 
gram in  an  inner-city  population.  Am  J Respir  Crit 
Care  Med.  1999;159:295-300. 

7.  Schluger  NW,  Huberman  R,  Wolinsky  N,  et  al.  Tu- 
berculosis infection  and  disease  among  persons 
seeking  social  services  in  New  York  City.  Int  J Tuberc 
Lung  Disease  1997;1:31-37. 


Mr  Falchook  is  a Srd-year  medical  student  at 
Louisiana  State  University  Health  Sciences  Center 
in  New  Orleans,  Louisiana. 

Mr  Gaffga  is  a 3rd-year  medical  student  at 
Louisiana  State  University  Health  Sciences  Center 
in  New  Orleans,  Louisiana. 

Ms  Eve  is  a nurse  practitioner  at 
Daughters  of  Charity  Neighborhood  Health  Partnership, 
Integrated  Mobile  Assessment  Treatment  Team  (IMATT). 

Dr  Ali  is  Associate  Professor  of  Medicine  and 
Director  of  LSU  TB  Clinics, 
Section  of  Pulmonary /Critical  Care, 
at  Louisiana  State  University  Health  Sciences  Center 

in  New  Orleans,  Louisiana. 


404  J La  State  Med  Soc  VOL  1 52  August  2000 


Kind  Strangers? 

Physicians  Through  the  Eyes  of 
Tennessee  Williams 

R.N.  McLay,  PhD;  B.  Lutz,  MD;  M.M.  Baden,  MD;  R.  Bray,  PhD;  S.  Griffies,  MD 


In  Louisiana,  Tennessee  Williams  is  usually  thought  of  as  a famous  denizen  of  the  French 
Quarter  or  perhaps  as  our  greatest  playwright.  Medicine  rarely  enters  into  it.  Illness,  however, 
particularly  mental  illness,  shaped  much  of  Williams'  life  and  his  work.  The  playwright  had 
mixed  feelings  about  physicians  and  their  effect  on  his  life  and  that  of  his  close  relations. 
These  feelings  worked  their  way  into  his  plays.  Through  it  all  Williams  gives  a vivid,  humorous, 
and  deeply  truthful  image  of  the  doctor-patient  relationship  in  the  first  half  of  the  twentieth 
century.  Here  we  give  a brief  review  of  medicine  in  Williams'  work. 


Over  sixty  years  after  its  perming.  Not 
About  Nightingales , the  "forgotten"  play 
by  Tennessee  Williams,  is  being  per- 
formed in  New  York.  It  was  nominated  for  six 
Tony  Awards,  demonstrating  perhaps  that  the 
old  master  playwright  still  has  some  important 
messages  to  communicate  to  the  modern  world. 
Among  the  more  interesting  aspects  of  Will- 
iams' work  is  the  way  in  which  he  portrays  phy- 
sicians and  the  physician-patient  relationship. 

The  only  play  by  Williams  that  was  purely 
about  medicine  is,  unfortunately,  lost  to  us. 
While  a student  at  The  University  of  Iowa,  Wil- 
liams was  assigned  to  write  a current  events 
play  on  the  subject  of  socialized  medicine,  but 
the  professor  who  had  made  the  assignment 


was  less  than  pleased  with  the  result.  Norman 
Felton,  a classmate  of  Williams  at  Iowa,  said  of 
what  happened  when  the  play  was  turned  in, 
"It  was  as  if  a volcano  had  erupted.  You  see,  the 
Boss  (Professor  E.C.  Mabie)  had  many  friends 
among  doctors  of  medicine  at  the  University.  The 
next  day  I heard  that  he  had  tom  up  Tom's  script."1 

The  same  so  called  "living  newspaper"  se- 
ries of  assignments  that  resulted  in  the  destroyed 
play  concerning  socialized  medicine  also  caused 
Williams  to  write  Not  About  Nightingales.2  This 
play  was  inspired  by  the  1938  story  of  four  in- 
mates in  a Philadelphia  prison  who  had  been 
scalded  to  death.  The  horrific  circumstances 
surrounding  their  demise  were  at  first  covered 
up  by  physicians  at  the  prison  and  then  eventu- 


J La  State  Med  Soc  VOL  152  August  2000  405 


ally  brought  to  light  by  the  New  York  coroner. 
A subversive  view  of  doctors  thus  may  have 
slipped  by  Williams'  disapproving  professors. 

Illness,  both  physical  and  mental,  lurks  as 
an  unnamed  character  in  many  works  of  Ten- 
nessee Williams.  The  American  dramatist  made 
famous  for  plays  such  as  Cat  on  a Hot  Tin  Roof,  A 
Streetcar  Named  Desire,  and  The  Glass  Menagerie 
had  mixed  feelings  about  physicians  and  their 
effect  on  his  life  and  his  close  relations.  Such 
conflicts  enter  into  many  of  his  works,  giving 
us  a vivid  image  of  the  doctor-patient  relation- 
ship in  the  first  half  of  the  twentieth  century. 

Perhaps  the  most  famous,  albeit  brief,  im- 
age of  a physician  in  a Tennessee  Williams'  play 
occurs  at  the  end  of  A Streetcar  Named  Desire.3 
Blanche,  a woman  who  throughout  the  play  has 
shown  signs  of  histrionic  personality  disorder 
and  perhaps  other  psychiatric  problems,  ap- 
pears to  have  suffered  an  acute  psychotic  break. 
Throughout  the  play  she  has  "misrepresented 
things",4  to  use  her  words,  but  she  was  not  de- 
lusional. After  having  been  humiliated,  raped, 
and  thrown  out  by  her  sister's  husband  how- 
ever, Blanche's  own  ability  to  differentiate  be- 
tween reality  and  fantasy  breaks  down. 

A doctor  and  nurse  arrive  to  collect  Blanche 
and  take  her  to  a mental  institution.  The  nurse, 
with  the  complicity  of  Stanley  and  the  others  in 
the  room,  seems  ready  to  apply  a straight] acket 
and  cart  Blanche  off  to  the  asylum  without  fur- 
ther ado.  The  physician  takes  a more  gentle  ap- 
proach. He  offers  his  arm  and  gently  leads 
Blanche  away,  a gesture  she  seems  to  trust.  "I 
have  always  depended  on  the  kindness  of 
strangers",  she  says.5 

Whether  the  physician  is  truly  offering 
Blanche  a kindness  is  left  to  hang  ambiguously 
at  the  end  of  the  play.  Williams  often  seems  to 
imply  that  there  is  little  that  physicians  can  re- 
ally do  for  patients.  In  works  such  as  "Miss 
Coynte  of  Green"6  and  Kingdom  of  Earth  (The 
Seven  Descents  of  Myrtle),7  doctors  are  impotent 
to  save  the  lives  of  dying  characters.  Even  the 
wealthy  Big  Daddy  in  Cat  on  a Hot  Tin  Roof  can- 
not gain  help  from  his  doctors,  only,  as  he  puts 
it,  "mendacity".8 


Williams  often  seems  to  imply  that  the  ac- 
tions of  physicians  work  only  as  a ritual,  a cer- 
emony that  can  cut  two  ways.  "You  will  take 
any  shot  or  pill  in  existence",  says  Elphinstone 
in  Happy  August  the  Tenth,  "not  because  you  are 
really  scared  of  illness  or  mortality,  but  because 
you  have  an  unconscious  death  wish  and  feel 
so  guilty  about  it  that  you  are  constantly  trying 
to  convince  yourself  that  you  are  doing  every- 
thing possible  to  improve  your  health  and  to 
prolong  your  life."9  The  need  to  seek  the  doctor 
is  as  much  a problem  as  the  illness  itself. 

Williams'  reservations,  as  expressed  in  his 
work,  were  well  founded  in  his  own  life.  In  his 
Memoirs,  Williams  accuses  at  least  one  doctor  of 
trying  to  kill  him.  "I  refuse  to  ascribe  to  para- 
noia my  conviction  that  the  resident  physician 
intended  to  commit  legalized  murder  upon  my 
person  and  very  nearly  succeeded",  he  says.10 
This  was  probably  a delusion  on  the  part  of 
Williams,  but  it  does  appear  true  that  physicians, 
particularly  a physician  called  "Dr.  Feel  Good" 
in  his  Memoirs,  encouraged  Williams'  addiction 
to  drugs. 

Gore  Vidal  said,  that  in  dealing  with  his 
problems,  "Tennessee  turned  to  drinking  and 
pills,  and  then,  worse,  to  witch  doctors.  One,  a 
medical  doctor,  hooked  him  on  amphetamines; 
another,  a psychiatrist,  tried  to  get  him  to  give 
up  writing  and  sex."11  As  with  the  characters  in 
his  plays,  illness  and  cure  were  quite  tangled  in 
Williams'  life.  What  parts  of  his  pathology  were 
real,  what  induced  by  doctors,  and  what  parts 
simply  imagined  were  never  clear.  As  Vidal  also 
said  of  Williams,  "he  punished  himself  with 
hypochondria."12 

It  might  also  be  said  that  Williams'  possible 
somatization  disorder  was  part  of  a spectrum 
of  disease  as  real  as  the  diphtheria  that  partially 
paralyzed  him  in  childhood.  Psychiatric  illness, 
evident  in  many  if  not  most  of  Williams'  works, 
was  also  a part  of  Williams'  real  world  life. 

Beginning  from  his  youth  in  college,  the 
playwright  was  plagued  by  severe  depression, 
a condition  he  referred  to  as  his  "blue  devils".13 
During  some  of  his  depressive  episodes  he  also 
experienced  hallucinations.  Drug  addiction  and 


406  J La  State  Med  Soc  VOL  152  August  2000 


anxiety,  sometimes  about  his  own  perceptions 
of  his  mental  illness,  compounded  his  difficul- 
ties. Doubtless  much  of  his  apprehension  over 
his  own  health  was  because  of  what  he  had  seen 
happen  to  his  sister  Rose. 

Rose,  the  presumed  inspiration  for  many  of 
Tennessee  Williams'  characters,  underwent  pro- 
longed treatment  for  severe  psychiatric  prob- 
lems. Eventually  her  psychoses  led  to  her  receiv- 
ing what  Williams  once  described  as  "the  first 
lobotomy  performed  in  Alabama".14  In  several 
interviews  Williams  suggested  that  the  decision 
to  perform  the  lobotomy  was  part  of  a con- 
spiracy to  silence  his  sister. 

The  facts  surrounding  Rose's  operation  are 
somewhat  different  than  those  presented  by  the 
playwright.  As  Dakin  Williams,  Tennessee's 
brother,  put  it,  "He  (Tennessee)  was  the  great- 
est playwright  who  ever  lived,  but  as  a human 
being  he  was  not  above  lying."15  Williams  regu- 
larly stated  the  lobotomy  was  performed  in  1937. 
In  fact,  the  operation  was  done  in  Missouri  in 
1943.  Critics  have  suggested  that  Williams  al- 
tered the  date  to  deflect  blame  from  himself.  In 
1937  he  was  a college  student  who  would  have 
been  able  to  do  little  to  prevent  the  operation. 
In  1943,  when  the  lobotomy  actually  occurred, 
he  was  a screenwriter  in  Hollywood  and  far 
from  penniless  or  powerless.  After  the  opera- 
tion, he  turned  his  full  attention  to  The  Glass 
Menagerie,  a play  often  regarded  as  Williams' 
greatest  and  the  most  closely  associated  with  his 
sister's  suffering. 

The  guilt  and  anger  Williams  felt  concern- 
ing his  sister's  treatment  appear  to  have  come 
out  in  several  of  his  works.  Dr  J.  Planter  Cash  in 
Stopped  Rocking 16  is  one  of  Williams'  more  men- 
acing characters.  The  name  of  the  physician  is 
itself  a dark  sort  of  pun.  In  the  play,  mental  pa- 
tients, when  they  have  become  so  catatonic  as 
to  stop  rocking,  are  placed  in  a ward  referred  to 
as  the  "vegetable  garden,"  planted  there,  so  to 
speak,  by  Dr  Planter.  Parts  of  this  play  were 
undoubtedly  taken  from  Tennessee's  visits  to  see 
his  sister  in  various  mental  institutions  through- 
out her  life. 

The  negative  feelings  Williams  may  have  felt 


toward  physicians  and  mental  institutions  did 
not  appear  to  cloud  his  ability  to  portray  doc- 
tors in  more  varied  forms.  Some  physicians,  such 
as  Dr  Cukrowicz  in  Suddenly  Last  Summer,17  are 
among  Williams'  more  dynamic  characters.  Dr 
Cukrowicz,  or  Dr  Sugar  as  some  like  to  call  him, 
starts  as  the  villain,  but  by  the  end  of  the  play 
the  audience  is  left  to  wonder  if  he  might  not  be 
the  hero  of  the  story,  saving  Catharine  from  a 
lobotomy. 

A more  unsavory  physician  is  the  character 
of  Doc  in  Small  Craft  Warnings.18  Doc  is  not  what 
one  would  normally  consider  a competent  doc- 
tor. He  swills  down  Benzedrine  before  going  to 
deliver  a baby.  When  the  baby  is  delivered  dead, 
and  the  mother  dies  in  delivery.  Doc's  response 
is  to  take  the  dead  body  of  the  child  and  let  it 
drift  off  in  the  ocean  in  a shoebox.  Despite  the 
lack  of  sympathy  in  the  role,  Williams  himself 
decided  to  play  the  part  of  Doc  in  the  play's  ini- 
tial running19  (a  position  that  heartily  annoyed 
the  other  actors  owing  to  Williams'  tendency  to 
ad  lib  on  stage). 

Other  doctors  in  Williams'  work  include 
Summer  in  Smoke's  John  Buchanan,  a man  who 
is  throwing  away  his  medical  talents  through 
his  dissipated  lifestyle.20  Dr  Scudder  in  Sweet 
Bird  of  Youth  performs  an  operation  on  a woman 
that  results  in  her  sterilization,  and  then  pro- 
ceeds to  get  engaged  to  her.21  In  The  Rose  Tattoo 
a physician  is  shown  who  is  very  sympathetic 
to  Serafina's  desire  to  have  her  husband's  body 
cremated.22  A priest  in  this  play  is  vehemently 
opposed  to  cremation,  and  Williams  makes  in- 
teresting play  of  the  potential  conflict  between 
the  roles  of  physician  and  priest. 

Tennessee  Williams  did  have  some  positive 
experiences  with  physicians.  He  believed  his 
treatment  for  depression  and  drug  addiction  in 
1958  by  Dr  Lawrence  Kubie  was  helpful.23  Some 
conflict  did  arise  out  of  his  sessions.  Dr  Kubie 
tried  to  convince  Williams  that  he  was  not  re- 
ally a homosexual.  (It  must  be  remembered  that 
until  1973  homosexuality  was  officially  consid- 
ered a mental  illness  by  the  American  Psychiat- 
ric Association.)24  At  the  time  Williams  was  be- 
ing psychoanalyzed,  he  was  involved  in  a rela- 


J La  State  Med  Soc  VOL  152  August  2000  407 


tionship  with  Frank  Merlo,  the  most  lasting  of 
Williams'  many  loves.  "Since  he  (Tennessee) 
could  not  (break  up  with  Frank  Merlo),  he  broke 
up  with  Dr  Kubie  instead."25  Others  have  reacted 
with  venom  against  this  attempt  to  transmogrify 
Williams'  sexuality,11  but  the  playwright  him- 
self seemed  to  appreciate  the  honest  attempts 
at  helping  him,  while  retaining  the  right  to  mock 
the  parts  of  his  therapy  that  were  misdirected. 

This  humorous  take  on  physicians,  particu- 
larly in  the  potential  sexuality  of  the  doctor-pa- 
tient relationship,  can  be  seen  in  works  such  as 
Moise  and  the  World  of  Reason.  In  this  novel,  Wil- 
liams gives  us  a scene  in  which  the  narrator  is 
interviewed  by  a psychiatry  student:26 

During  my  confinement  to  the  violent 
ward  on  that  little  island  in  the  River  East , 

I was  interviewed  once  a week  by  a student 
psychiatrist  whose  visits  I valued  nearly  as 
much  as  those  of  Moise.  He  wore  starched 
white , of  course , and  was  by  far  the  most 
agreeable  staff  member  to  look  at.  On  the 
days  of  his  visits  I would  not  only  bathe  with 
unusual  attention  to  detail  but  would  sham- 
poo my  hair  with  that  thinned  bar  of  laun- 
dry soap  in  the  men's  shower  so  that  my 
resemblance  to  the  young  Rimbaud  would 
be  accentuated. 

At  our  last  interview  he  said  to  me,  " I 
would  know  without  reference  to  your  file 
that  you  are  a sexual  deviant  by  the  way 
that  your  eyes  drop  continually  from  mine 
to  a part  of  my  body  which  is  only  concerned 
with  my  wife ...  .Look,  you're  tongue-tied 
and  blushing  for  no  reason,  this  is  a purely 
clinical  discussion. ". . . 

"Then  why  are  you  erected?" 

He  covered  it  with  his  flipbook. 

In  this  scene,  as  well  as  in  real  life,  Williams  ap- 
pears to  be  enamored  of  physicians,  while  at  the 
same  time  mocking  their  own  sense  of  self  im- 
port. He  notes  how  distant  and  heartless  those 
whose  job  it  is  to  offer  care  can  be.  Of  his  real- 
life  experience  with  bringing  his  lover,  Frank 
Merlo,  to  the  hospital  Williams  said,  "There  are 


some  things  that  I can't  forgive  Memorial  (hos- 
pital) for.  It  took  them  about  half  an  hour  to  bring 
up  the  oxygen  tank. . ..Frank  was  gasping  like  a 
hooked  fish  all  that  endless  half  hour."27  Frank 
Merlo  died  at  Memorial  Hospital  in  New  York 
in  1963.28 

Williams  often  wrote  about  the  futility  of  the 
treatments  offered  by  physicians.  Lot  dies  de- 
spite the  best  doctors.7  Blanche  goes  mad.4  To- 
day, modern  medical  practices  would  likely 
have  been  more  effective  in  treating  the  mala- 
dies that  afflicted  the  characters  in  the  works  of 
Tennessee  Williams.  Lot's  tuberculosis  would 
likely  have  been  cured  by  a combination  of  iso- 
niazid,  rifampin,  pyrazinamide,  and  ethambu- 
tol.  Blanche's  acute  psychosis  could  have  been 
brought  under  control  with  drugs  like 
risperidone  or  clozapine. 

Yet,  it  was  not  the  impotence  of  physicians 
that  Tennessee  seemed  to  resent.  It  was  their 
distance,  their  willingness  to  cover  things  up, 
their  false  kindness.  What  the  work  of  Tennes- 
see Williams  illustrates  is  a complaint  that  has 
not  lessened  with  the  passage  of  time  or  the  in- 
troduction of  new  pharmaceuticals.  Like  all 
great  literature,  the  work  of  Tennessee  Williams 
gives  us  a message  that  transcends  time,  even 
for  a field  that  changes  as  quickly  as  medicine. 
As  Gooper  said  in  Cat  on  a Hot  Tin  Roof,  "(A) 
doctor  has  got  a lot  on  his  mind  but  it  wouldn't 
hurt  him  to  act  a little  more  human."29  Timeless 
advice  from  the  old  master. 

REFERENCES 

1.  Leverich  L.  Tom:  The  Unknown  Tennessee  Williams. 
New  York:  Crown  Publishers;  1995:235. 

2.  Ibid,  p 234. 

3.  Williams,  Tennessee.  A Streetcar  Named  Desire.  New 
York:  Signet  Penguin  Putnam:  First  Printing 
October  1951:  Scene  Eleven. 

4.  Williams,  Tennessee.  A Streetcar  Named  Desire.  New 
York:  Signet  Penguin  Putnam;  First  Printing 
October  1951:  Scene  Nine. 

5.  Williams,  Tennessee.  A Streetcar  Named  Desire.  New 
York:  Signet  Penguin  Putnam;  First  Printing 
October  1951:  Scene  Eleven. 

6.  Williams,  Tennessee.  Mzss  Coynte  of  Green.  In: 
Tennessee  Williams  Collected  Stories.  New  York: 


408  J La  State  Med  Soc  VOL  1 52  August  2000 


Ballantine  Books;  1983. 

7.  Williams,  Tennessee.  Kingdom  of  Earth  (The  Seven 
Descents  of  Myrtle).  1975. 

8.  Williams,  Tennessee.  Cat  on  a Hot  Tin  Roof  New 
York:  New  Directions  Books;  1954:  Act  Three. 

9.  Williams,  Tennessee.  "Happy  August  the  Tenth". 
In:  Tennessee  Williams  Collected  Stories.  New  York: 
Ballantine  Books;  1983:495. 

10.  Williams,  Tennessee.  Memoirs.  Garden  City,  New 
York:  Doubleday;  1975:220. 

11.  Vidal,  Gore.  Introduction.  In:  Tennessee  Williams 
Collected  Stories.  New  York:  Ballantine  Books; 
1983:XXV. 

12.  Ibid.  p.  XXIV. 

13.  Leverich  L.  Tom:  The  Unknown  Tennessee  Williams. 
New  York:  Crown  Publishers;  1995:174. 

14.  Williams,  Tennessee.  As  quoted  by  Michael  Korda 
in  The  New  Yorker,  March  22,  1999:63. 

15.  Williams,  Dakin.  Spoken  at  the  1999  Tennessee 
Williams  Festival,  New  Orleans. 

16.  Williams,  Tennessee.  Stopped  Rocking.  In:  Stopped 
Rocking  and  Other  Screenplays.  New  York:  New 
Directions  Publishing;  1983. 

17.  Williams,  Tennessee.  Suddenly  Last  Summer.  First 
published  as  The  Garden  District.  London:  Martin 
Seeker  & Warburg;  1958. 

18.  Williams,  Tennessee.  Small  Craft  Warnings.  New 
York:  New  Directions  Books;  1970. 

19.  Tennessee  Williams  played  the  role  of  "Doc"  for 
the  first  five  performances  of  Small  Craft  Warnings 
at  the  New  York  Theatre  in  New  York,  starting  June 
6,  1972. 

20.  Williams,  Tennessee.  Summer  and  Smoke,  1948. 

21.  Williams,  Tennessee.  Sweet  Bird  of  Youth.  New  York: 
Two  Rivers  Enterprises;  1959. 

22.  Williams,  Tennessee.  The  Rose  Tattoo.  1950. 

23.  Hayman,  Ronald.  Tennessee  Williams  Everyone  Else 
Is  an  Audience.  New  Haven:  Yale  University  Press; 
1983:171. 

24.  Lamberg  L.  Gay  is  okay  with  APA — forum  honors 
landmark  1973  events.  JAMA  1998;280:497-499. 

25.  Williams  D,  Mead  S.  Tennessee  Williams:  an  Intimate 
Biography.  New  York:  Arbor  House;  1983:215. 

26.  Williams,  Tennessee.  Moise  and  the  World  of  Reason. 
New  York:  Simon  and  Schuster;  1975. 

27.  Williams,  Tennessee.  Memoirs.  Garden  City,  New 
York:  Doubleday;  1975:194. 

28.  Saddik,  Annette  J.  The  Politics  of  Reputation. 
Cranbury,  NJ:  Associated  University  Presses;  1999. 

29.  Williams,  Tennessee.  A Cat  on  a Hot  Tin  Roof.  New 
York:  New  Directions  Books;  1954:  Act  Three. 


Dr  McLay  is  a medical  student  at  Tulane  University 
School  of  Medicine  in  New  Orleans,  Louisiana. 

Dr  Lutz  is  Chief  of  Internal  Medicine  at  Baptist  Hospital 

in  New  Orleans,  Louisiana. 

Dr  Baden  is  a forensic  pathologist. 

Dr  Bray  is  Professor  of  English  at  Middle  Tennessee 
State  University,  Program  Chair  for  the 
Tennessee  Williams  Scholars'  Conference,  and 
Editor  of  the  Tennessee  Williams  Annual  Review. 

Dr  Griffies  is  Assistant  Professor  of  Psychiatry  at 
Louisiana  State  University  Medical  School 
in  New  Orleans,  Louisiana. 


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J La  State  Med  Soc  VOL  1 52  August  2000  41  1 


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J La  State  Med  Soc  VOL  152  August  2000  413 


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Diagnostic  Imaging  

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The  Trust  Company  of  LA 

Inside  Back  Cover 

Tulane  School  of  Public  Health 

376 

414  J La  State  Med  Soc  VOL  1 52  August  2000 


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ESTABLISHED  1844 


Of  the  Louisiana  State  Medical  Society 


Long-Term  Sterilization  Failure:  Twenty-Three  Years 


ECG  Report  of  the  Month:  Concordance  or  Discordance 


Radiology  Case  of  the  Month:  Painful  Eye 
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Editor 

CONWAY  S.  MAGEE,  MD 

Chief  Executive  Officer 

DAVE  TARVER 

General  Manager 

CATHY  LEWIS 

Managing  Editor 

ANNE  SHIRLEY 

Administrative  Assistant 

MELISSA  CANTRELL 

Advertising  Sales 

ANNE  GOOCH 


Of  the  Louisiana  State  Medical  Society 


BOARD  OF  TRUSTEES 
Chairman,  CONWAY  S.  MAGEE.  MD 
K.  BARTON  FARRIS,  MD 
Ex  officio,  C.  Clinton  Lewis,  MD 

EDITORIAL  BOARD 


A.  JOANNE  GATES,  MD 
RODNEY  C.  JUNG,  MD 


PATRICK  W.  PEAVY,  MD 
TRENTON  L.  JAMES  II,  MD 
JACK  P.  STRONG,  MD 

Harvey  T.  Huddleston,  MD 
Dale  R.  Dunnihoo,  MD,  PhD 

427 

Long-Term  Sterilization  Failure: 
Twenty-Three  Years 

CLAY  A.  WAGGENSPACK  JR,  MD 
WINSTON  H.  WEESE,  MD 

Richard  A.  Spector,  MD 

429 

Mediation  in  Medical  Liability  Litigation 

LSMS  BOARD  OF  GOVERNORS 
C.  CLINTON  LEWIS,  MD 

Michael  S.  Ellis,  MD 

436 

The  Internet  for  Louisiana  Physicians 

DUDLEY  M.  STEWART,  MD 
KEITH  DESONIER.  MD 

Bobby  Jindal 

454 

Providing  Access  to  Prescription  Drugs 
for  America's  Retirees 

LEO  L.  LOWENTRITT  JR,  MD 
K.  BARTON  FARRIS.  MD 


RUSSELL  C.  KLEIN,  MD 
WALLACE  H.  DUNLAP.  MD 
VINCENT  A.  CULOTTA  JR,  MD 
RICHARD  J.  PADDOCK,  MD 
BARRY  G.  LANDRY,  MD 
WILLIAM  T.  HALL,  MD 
JOSEPH  BUSBY  JR.  MD 
LYNN  2.  TUCKER,  MD 
R.  MARK  WILLIAMS.  MD 


MARTIN  B.  TANNER.  MD 
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JOSHUA  LOWENTRITT.  MD 

416 

INFORMATION  FOR  AUTHORS 

LAURA  BRESNAHAN  ROBERTS 

ESTABLISHED  1844.  Owned  and  edited  by  the 

Jorge  1.  Martinez-Lopez,  MD 

419 

ECG  OF  THE  MONTH 
Concordance  or  Discordance 

Journal  of  the 
Louisiana  State  Medical  Society,  Inc., 

Sanjay  M.  Patel,  MD 

423 

RADIOLOGY  CASE  OF  THE  MONTH 

6767  Perkins  Road,  Baton  Rouge,  LA  70808: 
phone:  (225)  763-2310:  fax:  (225)  763-2332. 

e-mail:  publicaffairs@lsms.org 

Jessica  Borne,  MD 
Harold  Neitzschman,  MD 

Painful  Eye 

Internet:  www.lsms.org 
Copyright  2000  by  the  Journal  of  the 

Gustavo  Colon,  MD 

425 

JOURNAL  1 00  & 1 50  YEARS  AGO 
Some  Interesting  Notes 

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The  Journal  of  the  Louisiana  State  Medical  Society 

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at  6767  Perkins  Road,  Louisiana  State  Medical  Society, 
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Articles  and  Advertisements  published  in  the  Journal 
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necessarily  represent  the  official  position  or 
endorsement  of  the  Journal  of  the  Louisiana 
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Louisiana  State  Medical  Society. 

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Information  for  Authors 


The  Journal  is  published  for  the  benefit  of  the  members  of  the  Louisiana  State 
Medical  Society.  Manuscripts  should  be  of  interest  to  a broad  spectrum  of  phy- 
sicians and  designed  to  provide  practical  information  on  the  current  status 
and  the  progress  and  changes  in  the  field  of  clinical  medicine.  The  articles 
published  are  primarily  original  scientific  studies  but  may  include  societal, 
socioeconomic,  or  medicolegal  topics. 

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Each  submission  is  reviewed  by  the  editor  and  is  subject  to  peer  review  by  one 
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The  final  decision  to  accept  or  revise  falls  to  the  editor. 

Preparation  of  the  Typescript 

Allow  margins  of  at  least  1 inch  on  all  sides;  avoid  end-of-line  hyphens;  num- 
ber all  pages,  starting  with  the  title  page;  begin  each  major  part  of  the  manu- 
script on  a new  page;  double-space  all  parts  of  the  manuscript.  Submit  the 
manuscript  in  triplicate. 

Computer  Disk 

When  the  manuscript  has  been  accepted,  the  author  will  be  asked  to  submit  a 
3.5"  diskette  with  language  exactly  matching  that  of  the  accepted  version. 

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Units  of  measure.  Use  conventional  units.  If  essential,  SI  units  may  be 
added  in  parentheses  immediately  following  the  conventional  expression. 

Drug  names.  Use  the  generic  form.  If  the  proprietary  name  is  relevant  to 
the  study,  it  may  be  added  in  parentheses  immediately  following  the  first  men- 
tion of  the  generic  name.  A generic  name  is  lowercased;  a proprietary  name  is 
capitalized. 

Citing  a reference  entry.  Use  superior  arabic  numerals  placed  at  the  logi- 
cal site  in  the  sentence;  insert  immediately  after  a word  or  mark  of  punctua- 
tion; set  close.  Cite  in  the  main  text,  in  tables,  and  in  the  legends  for  illustra- 
tions; do  not  cite  in  the  abstract. 

Parts  of  the  Manuscript 

Title  page.  The  title  page  should  carry  the  following  information:  (1)  The 
title  of  the  manuscript,  which  should  be  concise  but  informative.  (2)  The  full 
name  of  each  author  together  with  his  highest  academic  degree  relevant  to  the 
subject  matter  of  the  paper.  List  authors  in  the  order  of  the  magnitude  of  their 
contribution.  List  as  authors  only  those  who  have  contributed  materially  to 
the  conduct  of  the  study  or  to  the  preparation  of  the  manuscript.  (3)  The  affili- 
ation of  each  author  at  the  time  the  study  was  done.  (4)  Explanatory  notes  that 
give  (a)  a brief  biographical  note  for  each  author  indicating  his  academic  ap- 
pointments, hospital  affiliations,  and  practice  location;  and  (b)  the  name  and 
address  of  the  author  to  whom  requests  for  reprints  should  be  addressed  or  a 
statement  that  reprints  will  not  be  available. 

Abstract  and  Keywords.  Give  a brief  recapitulation  of  the  purpose  of  the 
paper,  the  methods  and  subjects  used,  the  results,  and  the  conclusions;  avoid 
acronyms  and  abbreviations,  do  not  cite  sources  listed  in  the  references  sec- 
tion (the  abstract  must  stand  alone);  limit  the  abstract  to  150  words. 

On  the  lower  part  of  the  same  page,  list  three  to  five  key  words  or  short 
phrases  that  will  assist  indexers.  Use  terms  from  Medical  Subject  Headings  as 
used  in  Index  Medicus  when  possible. 

Main  Text.  Avoid  highly  technical  expressions  and  jargon;  the  article  should 
be  easily  understood  by  the  general  readership. 

Use  subheads  freely  to  break  the  typographic  monotony,  make  the  paper 
easier  to  read,  and  fortify  the  sequence  of  the  author's  argument.  Commonly 
used  subheads  are:  introduction  or  background,  methods  and  subjects,  re- 
sults, discussion,  and  conclusions. 

Acknowledgments.  Acknowledgments  must  be  made  for  financial  assis- 
tance (grants,  equipment,  drugs)  and  for  the  use  of  previously  published  ma- 
terial. Acknowledgment  may  be  made  for  technical  assistance  and  intellectual 
participation  in  conducting  the  study  or  preparing  the  manuscript. 

References.  Each  source  dted  in  the  main  text,  tables,  or  legends  must  be 
listed  in  the  references  section;  and,  conversely,  all  entries  in  the  references 
section  must  have  been  cited  in  the  main  text,  tables,  or  legends. 

Each  reference  entry  is  composed  of  three  elements:  (1)  the  name  of  the 
author,  (2)  the  title  of  the  article  or  book,  and  (3)  the  imprint.  The  following 


three  examples  illustrate  the  reference  style  adopted  by  the  Journal  for  (1)  a 
reference  to  an  article  in  a journal,  (2)  a reference  to  a book  or  monograph, 
and  (3)  a reference  to  a part  of  a larger  work. 

1.  Brush  JE  Jr,  Cannon  RO  III,  Schenke  WH,  et  al.  Angina  due  to  coro- 
nary microvascular  disease  in  hypertensive  patients  without  left  ven- 
tricular hypertrophy.  N Engl  J Med  1988;319:1302-1307. 

2.  Hajdu  SI.  Pathology  of  Soft  Tissue  Tumors.  Philadelphia,  Pa:  Lea  & 
Febiger;  1979:60-83. 

3.  Robinson  BH.  Lactic  acidemia.  In:  Scriver  CR,  Beaudet  AL,  Sly  WS, 
et  al  (editors).  The  Metabolic  Basis  of  Inherited  Disease,  6th  edition. 
New  York:  McGraw-Hill;  1989:869-888. 

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416  J La  State  Med  Soc  VOL  152  September  2000 


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ECG  of  the  Mont 


Concordance  or  Discordance 

Jorge  I.  Martinez-Lopez,  MD 


The  12-lead  ECG  and  rhythm  strip  (limb  lead  II)  shown  below  belongs  to  a 63-year-old  man. 
It  was  recorded  in  the  Heart  Station. 


LOC  OdOfll-OOOl  Speed : 23  mm/tce  LiabilO  ■■/■V  Cbetl:10  mm/iV 


What  is  your  diagnosis? 
Elucidation  begins  on  page  420. 


J La  State  Med  Soc  VOL  152  September  2000  419 


ECG  of  the  Month 
Presentation  is  on  page  419. 

DIAGNOSIS  - Complete  left  bundle  branch  block 

Normal  sinus  rhythm,  at  88  beats  a minute,  and 
a normal  PR  interval  are  present.  Every  P wave 
is  followed  by  a wide  QRS  complex  that  mea- 
sures 0.14  sec.  The  abnormal  width  of  the  QRS 
complexes  is  caused  by  abnormal  intraventricu- 
lar conduction.  These  wide  QRS  complexes  have 
the  characteristic  morphology  of  complete  left 
bundle  branch  block  (LBBB). 

When  complete  LBBB  occurs,  supraventricu- 
lar impulses  are  conducted  into  the  ventricles  by 
way  of  the  intact  right  bundle  branch;  the  left 
ventricle — which  has  the  non-conducting  bundle 
branch — is  depolarized  later  than  the  right  ven- 
tricle. Depolarization  of  the  left  ventricle,  there- 
fore, proceeds  from  right  to  left,  and,  after  cross- 
ing the  interventricular  septum,  the  wavefront 
spreads  through  the  working  myocardial  cells 
of  the  left  ventricle  more  slowly.  The  delayed 
depolarization  of  the  left  ventricle  and  the  re- 
sulting asynchronism  in  biventricular  depolar- 
ization cause  the  observed  widening  of  the  QRS. 

In  limb  leads  II,  III,  and  AVF,  and  in  V5-V6, 
ST  segments  are  depressed  and  T waves  are  in- 
verted. Conversely,  in  leads  showing  negatively- 
oriented  QRS  complexes,  such  as  limb  leads  I 
and  AVL,  and  precordial  leads  V^-V^  ST  seg- 
ments are  "elevated"  and  tall,  upright  T waves 
are  present.  These  ST-T-wave  abnormalities  are 
typical  of  those  that  are  secondary  to  complete 
LBBB,  and  represent  abnormal  biventricular  re- 
polarization; collectively,  these  ST-T  wave 
changes  are  described  as  showing  "appropriate 
discordance". 

Because  of  the  abnormal  depolarization  of  the 
interventricular  septum  in  complete  LBBB — 
from  right  to  left,  rather  than  left  to  right — the 
so-called  "septal"  R wave  is  absent,  a finding 
which  may  mimic  anteroseptal  infarction.  This 
pseudo-infarction  pattern  (QS)  can  be  seen  in 
precordial  leads  V1-V3  in  the  tracing  shown  here. 

Conversely,  complete  LBBB  may  mask  ECG 


manifestations  of  acute  or  of  remote  myocardial 
infarction.  However,  close  inspection  of  the  12- 
lead  ECG  is  often  helpful  in  predicting  acute 
myocardial  infarction  in  the  presence  of  a com- 
plete LBBB,  if  one  keeps  in  mind  the  rule  of  ap- 
propriate discordance.  The  key  finding  is  that 
ST  segments  in  acute  myocardial  infarction  with 
complete  LBBB  are  displaced  in  the  same  direc- 
tion as  the  QRS  complexes  (described  as  inap- 
propriate concordance).  For  example,  the  clinical 
suspicion  of  an  acute  myocardial  infarction  in 
patients  with  complete  LBBB  is  supported  by 
one  or  more  of  the  following  findings:  ST  seg- 
ment depression  of  one  or  more  millimeters  in 
precordial  leads  V1-V3;  ST  segment  elevation  of 
one  or  more  millimeters  that  is  concordant  with 
the  QRS  complex;  and/or  ST  segment  elevation 
greater  than  5 millimeters,  which  is  discordant 
with  the  QRS  complex.  A sign  of  remote  myo- 
cardial infarction  is  the  presence  of  deep  and 
broad  Q waves  in  either  the  inferior  limb  leads 
or  the  anterolateral  precordial  leads.  None  of  the 
above  findings  are  present  in  the  tracing  under 
discussion;  all  the  findings,  thus  far,  seem  to  fit 
in  with  an  uncomplicated  complete  LBBB. 

Some  intraventricular  conduction  blocks 
produce  a shift  in  the  electrical  axis  of  the  QRS 
in  the  frontal  leads.  For  example,  block  in  the 
left  anterior  fascicle  of  the  left  bundle  branch 
causes  abnormal  left  axis  deviation,  whereas 
block  in  its  left  posterior  fascicle  shifts  the  elec- 
trical axis  to  the  right.  In  the  presence  of  com- 
plete LBBB,  the  frontal  plane  QRS  electrical  axis 
may  be  normal,  or  it  may  be  abnormally  shifted 
to  the  left  or  to  the  right.  Examination  of  the  fron- 
tal leads  in  the  tracing  reveals  right  axis  devia- 
tion, an  uncommon  occurrence;  the  exact  clini- 
cal significance  of  this  abnormal  finding  is  not 
clear.  Most  cases  of  complete  LBBB  are  caused 
by  diffuse  involvement  of  the  distal  left  bundle 
branch  system  and  do  not  represent  a truly  com- 
plete block  of  the  proximal  or  main  left  bundle 
branch.  Therefore,  the  right  axis  deviation  re- 
corded in  this  tracing  may  indicate  more  severe 
involvement  in  the  inferior  wall  of  the  left  ven- 
tricle than  in  the  anterior  wall. 

Last,  broad  and  notched  P waves,  recorded 


420  J La  State  Med  Soc  VOL  1 52  September  2000 


in  the  inferior  limb  leads,  are  consistent  with 
biatrial  enlargement. 

The  patient  presented  to  the  Heart  Station 
with  a page  from  the  prescription  pad  of  his  pri- 
vate care  physician,  requesting  an  ECG;  no  clini- 
cal information  was  provided.  Nevertheless,  it 
is  important  to  recall  that  complete  LBBB  virtu- 
ally always  indicates  organic  (structural)  heart 
disease  and  that,  in  most  cases,  it  is  associated 
with  either  ischemic  or  hypertensive  heart  dis- 
ease, or  both.  This  conduction  abnormality  does 
not  produce  symptoms  and,  in  itself,  does  not 
require  treatment. 


Dr  Martinez-Lopez  is  a specialist  in  cardiovascular 
diseases  affiliated  with  the  Cardiology  Service , Department 
of  Medicine,  Texas  Tech  University  Health  Sciences  Center 
and  Thomason  General  Hospital  in  El  Paso,  Texas. 


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J La  State  Med  Soc  VOL  152  September  2000  421 


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Radiology  Case  of  the  Month 


Painful  Eye 

Sanjay  M.  Patel,  MD;  Jessica  Borne,  MD;  Harold  Neitzschman,  MD 


A 25-year-old  man  presented  with  pain  and  swelling  of  his  right  eye.  He  denied  history  of 
trauma.  There  were  no  systemic  symptoms.  Physical  examination  revealed  redness  of  the  right 
eye.  There  was  no  proptosis.  Laboratory  studies  including  thyroid  functions  were  within  nor- 
mal limits. 


Figure  1.  Axial  computed  tomographic  image 
through  the  orbit. 


Figure  2.  Coronal  computed  tomographic 
image  through  the  orbit. 


What  is  your  diagnosis? 
Elucidation  is  on  page  424. 


J La  State  Med  Soc  VOL  152  September  2000  423 


REFERENCES 


Radiology  Case  of  the  Month 
Case  Presentation  is  on  page  423. 

RADIOLOGIC  DIAGNOSIS  - Orbital  myositis 
(orbital  pseudotumor) 


INTERPRETATION  OF  IMAGES 

Figure  1:  Axial  computed  tomographic  image 
through  the  orbit  demonstrates  streaky  den- 
sity in  the  retrobulbar  fat.  Figure  2:  Coronal 
computed  tomographic  image  through  the  or- 
bit demonstrates  streaky  density  in  the  retrob- 
ulbar fat.  There  is  asymmetric  enlargement  of 
the  inferior  rectus  muscle  with  ragged  and 
fluffy  borders. 

DISCUSSION 

Orbital  myositis  is  an  idiopathic  type  of  pseudo- 
tumor. One  or  more  extraocular  muscles  are 
primarily  infiltrated  by  the  inflammatory  pro- 
cess. The  disease  process  may  be  bilateral.  Pre- 
sentation can  be  acute,  subacute,  or  chronic. 
Important  clinical  findings  are  ocular  pain, 
diplopia,  proptosis,  conjunctival  chemosis,  re- 
stricted eye  motility,  and  swelling  of  eyelids.1 

A computed  tomographic  finding  in  orbital 
myositis  is  enlargement  of  extraocular  muscles 
extending  to  involve  the  musculotendinous  in- 
sertion. Other  helpful  indicators  include  a 
ragged,  fluffy  border  of  the  involved  muscle, 
with  infiltration  and  obliteration  of  the  fat  in 
the  peripheral  surgical  space  between  the  pe- 
riosteum of  the  orbital  wall  and  the  muscle 
cone.2  Infiltration  of  intraconal  fat  is  also  evi- 
dent. 

Grave's  disease  is  the  major  differential  di- 
agnosis. It  is  associated  with  systemic  symp- 
toms, painless  in  onset,  asymmetric,  and 
slowly  progressive.  The  myopathy  is  fusiform 
without  involvement  of  the  muscle  tendon  in- 
sertion. 


1.  Bittar  MS,  Garcia  ML,  Marchiori  PE.  Acute  orbital 
myositis:  case  report.  Arquivos  de  Neuro-Psiquiatria. 
1997;55:136-138. 

2.  Mafee  MF.  Eye  and  Orbit.  In:  Som  PM,  Curtin  RT. 
Head  and  Neck  Imaging.  St  Louis,  Missouri:  Mosby; 
1996:1096-1099. 


Dr  Patel  is  a fellow  at 
Louisiana  State  University  Health  Sciences  Center, 

New  Orleans,  Louisiana. 

Dr  Borne  is  an  associate  professor  of  Radiology  at 
Louisiana  State  University  Health  Sciences  Center, 

New  Orleans,  Louisiana. 

Dr  Neitzschman  is  a professor  of  Radiology  at 
Tulane  University  Health  Sciences  Center, 
New  Orleans,  Louisiana. 


424  J La  State  Med  Soc  VOL  152  September  2000 





Some  Interesting  Notes 


Gustavo  Colon,  MD 


Summer  is  a lax  time  even  in  medical  writ- 
ing 100  and  150  years  ago.  Therefore, 
some  of  the  journal  articles  are  less  than 
fascinating,  most  of  these  dealing  primarily  with 
the  multiple  fevers  and  agues  that  occurred  in 
the  South.  So  in  reviewing  many  of  the  journals, 
I thought  I would  bring  to  light  some  of  the  more 
interesting  notices  that  have  appeared  in  jour- 
nals in  the  past  in  hopes  that  this  would  reveal 
a snapshot  of  medical  ideas  of  that  period. 

From  the  August  1891  Journal  comes  the  fol- 
lowing article  about  contract  practice  in  Berlin 
[shades  of  managed  care].  A Berlin  correspon- 
dent of  the  Therapeutic  Gazette  gives  some  racy 
news  from  the  German  Capital.  The  correspon- 
dent describes  the  evils  of  contract  practice.  'The 
Berlin  physicians  are  now  greatly  agitated  by 
the  physicians  of  sick  benefit  societies.  Hitherto, 
a patient  member  of  such  a society  was  com- 
pelled to  consult  the  doctor  of  the  society  who 
received  a yearly  salary  for  services.  As  all  Ber- 
lin working  men  and  women  are  legally  com- 


pelled to  belong  to  a sick  benefits  society,  the 
work  of  doctors  elected  by  such  a society  is  natu- 
rally an  enormous  one.  Their  houses  are  actu- 
ally besieged  by  patients  while  hundreds  of 
other  physicians  have  no  patients  at  all.  The  con- 
sultations which  the  "society  doctors"  grant  each 
patient  are  ridiculously  short  and  absolutely  in- 
capable of  benefiting  their  patients.  I have  heard 
of  doctors  seeing  over  100  patients  a day  and 
also  note  the  number  of  minutes  allotted  to  vari- 
ous consultations.  For  example: 


Minor  surgical  cases 
Gonorrheal  infections 
Headache  and  other  pain 
Influenza 
Rheumatism 
Examination  of  the  lungs 


15  minutes 
10  minutes 

05  minutes 

06  minutes 
06  minutes 
05  minutes 


"It  is  evident  that  this  state  of  affairs  is  an  im- 
proper one  and  equally  undesirable  for  both  pa- 
tients and  doctors,  and,  to  enhance  the  morbid 


J La  State  Med  Soc  VOL  152  September  2000  425 


character  of  the  affair,  the  compensation  of  the 
physicians  is  a ridiculously  low  figure  usually 
about  two  cents  per  consultation  on  average.  This 
figure  is  not  this  correspondent's  fancy  but  has 
been  officially  fixed  by  statistical  investigation 
and  has  been  published  and  broadcast  to  all  pa- 
pers and  is  what  the  doctors  are  allowed  to 
charge.  Imagine  the  "blissful"  state  of  the  prac- 
titioner rewarded  by  two  cents  for  a consulta- 
tion of  the  chest,  but  at  last  Berlin  doctors  have 
waken  up  and  have  taken  steps  towards  the  ex- 
tinction of  this  shameful  condition." 

Then  there  is  this  little  piece  of  medical  in- 
formation which  gives  some  credence  to  an  old 
wives  tale  which  all  adolescents  have  heard  at 
one  time  and  it's  titled  Masturbation  and  Oph- 
thalmia. In  the  May  issue  of  the  Louisville  Medi- 
cal Herald , Dr  M.  Landus  states  that  he  has  had  a 
number  of  cases  of  chronic  catarrhal  conjunc- 
tivitis, which  were  totally  intractable  under  the 
ordinary  codes  of  treatment.  Gradually,  he  came 
to  trace  a connection  between  masturbation  and 
this  infection,  and,  on  breaking  up  the  habit,  he 
found  no  difficulty  in  relieving  the  morbid  con- 
dition. The  paper  is  illustrated  by  a number  of 
instructive  cases.  [I  can  hardly  wait  for  the  next 
paper,  which  certainly  will  discuss  juvenile  de- 
mentia.] 

And  finally,  this  little  ditty  that  comes  out 
of  the  Journal  entitled  Modern  Medicine,  a take 
off  on  the  excessive  use  of  inoculative  medi- 
cine in  the  1890s. 

First  they  pumped  him  full  of  virus  from 
some  mediocre  cow; 

Lest  the  small-pox  might  assail  him,  and 
leave  pit-marks  on  his  brow; 

Then  one  day  a bull  dog  bit  him  — he  was 
gunning  down  at  Quogue  — 

And  they  filled  his  veins  in  Parish  with 
an  extract  of  mad  dog; 

Then  he  caught  tuberculosis,  so  they  took 
him  to  Berlin, 

And  injected  half  a gallon  of  bacilli  into 
him; 

Well  his  friends  were  all  delighted  at  the 
quickness  of  the  cure. 


Till  he  caught  the  typhoid  fever,  and 
speedy  death  was  sure; 

Then  the  doctors  with  some  sewage  did 
inoculate  a hen. 

And  injected  half  its  gastric  juice  into  his 
abdomen; 

But  as  soon  as  he  recovered,  as  of  course 
he  had  to  do. 

There  came  along  a rattlesnake  and  bit  his 
thumb  in  two; 

Once  again  his  veins  were  opened  to 
receive  about  a gill 

Of  some  serpentine  solution  with  the 
venom  in  it  still; 

To  prepare  him  for  a voyage  in  an  Asiatic 
sea. 

Now  blood  was  pumped  into  him  from  a 
leprous  old  Chinese; 

Soon  his  appetite  had  vanished,  and  he 
could  not  eat  at  all; 

So  the  virus  of  dyspepsia  was  injected  in 
the  fall; 

But  his  blood  was  so  diluted  by  the 
remedies  he'd  taken 

That  one  day  he  laid  down  and  died,  and 
never  did  awaken; 

With  the  Brown-Sequard  elixir  though 
they  tried  resuscitation. 

He  never  showed  a symptom  of  reviving 
animation; 

Yet  his  doctor  still  could  have  saved  him 
(he  persistently  maintains). 

If  he  only  could  inject  a little  life  into  his 
veins. 


Dr  Colon  has  a plastic  surgery  practice  in  Metairie, 
Louisiana.  He  has  lectured  on  the  history  of  medicine  at 
LSU  Health  Sciences  Center — New  Orleans,  and 
Tulane  University  Health  Sciences  Center 
in  New  Orleans,  Louisiana. 


The  author  and  the  Journal  welcome  comments  on 
the  history  of  medicine. 


426  J La  State  Med  Soc  VOL  152  September  2000 


Long-Term  Sterilization  Failure: 
Twenty-Three  Years 

Harvey  T.  Huddleston,  MD;  Dale  R.  Dunnihoo,  MD,  PhD 


This  case  presents  the  longest  time  interval  from  tubal  sterilization  to  failure  by  ectopic 
pregnancy  of  which  we  or  our  colleagues  have  ever  heard.  This  multipara  had  a postpartum 
sterilization  procedure  performed  at  one  University  Hospital;  23  years  later  she  was  admitted 
to  another  University  Hospital  with  a hemoperitoneum  due  to  a ruptured  ectopic  pregnancy. 
Verification  was  affirmed  by  examination  of  the  records  of  both  hospitals. 


"If  it  can  happen;  it  will  happen." 

We  have  had  the  opportunity  to  care  for  a 
patient  suffering  from  the  complication  of  failed 
tubal  sterilization  which  we  believe  to  be  un- 
usually distant  from  the  time  of  the  original  sur- 
gery. An  extensive  review  of  the  available  da- 
tabases, by  the  Medical  Communications  De- 
partment at  LSU  Medical  Center  Library,  could 
not  retrieve  a published  reference  of  a tubal  ster- 
ilization failure  which  exceeded  this  number  of 
years.  Therefore,  we  present  our  case  as  an  ex- 
ample of  "extremus",  when  considering  tubal 
sterilization  failure. 


CASE  REPORT 

CDC  #81-183-296.  A 45-year-old  black  woman, 
born  April  2,  1945,  was  admitted  to  the  Emer- 
gency Room  of  the  University  Hospital,  Louisi- 
ana State  University  Medical  Center,  Shreveport, 
on  December  1,  1991  complaining  of  the  acute 
onset  of  postcoital,  right  lower  quadrant  pain. 
She  was  acutely  ill,  diaphoretic,  and  writhing  in 
pain.  Her  BP  was  88  / 56,  she  was  tachycardic  and 
hypercapnic,  and  had  a positive  "tilt  test".  Physi- 
cal examination  further  revealed  hypoactive 
bowel  sounds,  a slightly  protruberant,  tightly 


J La  State  Med  Soc  VOL  152  September  2000  427 


distended  abdomen  which  percussed  dull  ex- 
cept for  the  stomach  bubble  in  the  left  epigas- 
trium. Acute  tenderness  could  be  elicited  by 
percussion  and  palpation  from  the  symphysis 
to  above  the  umbilicus.  Pelvic  examination  was 
limited  because  of  acute  pain;  however, 
culdecentesis  revealed  non-clotting  blood.  Im- 
mediate laparotomy  was  performed.  A hemo- 
peritoneum  secondary  to  a ruptured  right  ec- 
topic pregnancy  was  present.  A right  salpingo- 
oophorectomy  was  performed,  from  which  she 
recovered  without  incident. 

Postoperatively,  anamnesis  revealed  she  had 
been  discharged  from  Parkland  Hospital,  Dal- 
las, Texas,  23  years  previously  after  an  obstetri- 
cal delivery  and  postpartum  tubal  ligation.  Be- 
cause of  the  inordinate  length  of  time  from  sur- 
gery to  sterilization  failure,  we  sought  confirma- 
tion data  from  Parkland  Hospital,  and  their 
records  affirmed  the  dates  in  an  operative  re- 
port which  stated:  "...  lifting  a knuckle  of  tube, 
cross-clamping  it  with  a Kelley  and  ligating  the 
knuckle  with  #1  chromic  and  excising  two  cm 
segments  bilaterally".  An  accompanying  Pathol- 
ogy report  also  confirmed  sectioning  of  both 
Fallopian  tubes. 

DISCUSSION 

Claiming  primacy  ordinarily  adds  little  to  a pa- 
per and  frequently  brings  embarrassment  when 
others  prove  they  had  already  reported  such  a 
case  or  a more  severe  form.  Notwithstanding,  a 
review  of  the  literature  corroborates  our  case  of 
a 23-year  tubal  sterilization  failure  as  being  an 
extreme  one,  even  if  not  the  most  extreme.  This 
late  failure  is  contrary  to  the  popular  notion  that 
if  a sterilization  procedure  is  going  to  fail,  it  fails 
early,  usually  within  the  first  2 years.  Peterson 
et  al  have  reported  that  the  risk  of  ectopic  preg- 
nancy does  continue  beyond  10  years.1  They  also 
identified  four  risk  factors  for  ectopic  pregnancy: 
(1)  Method  - bipolar  cautery,  (2)  Age  at  steriliza- 
tion - <30  yrs  of  age,  (3)  Race  - non-Hispanic 
Black,  and  (4)  Presurgical  history  ofPID.  Our  case 
exhibited  two  of  the  four  risk  factors,  ie,  num- 
bers 2 and  3. 


Closer  scrutiny  of  our  patient's  past  history, 
for  factors  which  may  have  caused  or  contrib- 
uted to  the  surgical  failure,  revealed  that  during 
those  23  years  she  had  been  variously  married, 
separated,  and  at  other  times  lived  with  differ- 
ent men.  There  was  no  history  of  pelvic  infec- 
tions, nor  did  she  take  cortisone,  have  a hystero- 
salpingogram,  laparoscopy,  or  laparotomy  dur- 
ing that  interval.  Regarding  contraception,  she 
stated:  "I  never  used  protection  if  I knew  the 
man;  if  I didn't,  we  used  a condom." 

This  case  may  not  demonstrate  the  longest 
time  interval  from  sterilization  to  failure  that  has 
ever  occurred,  but  it  is  the  longest  of  which  we 
and  our  colleagues  have  heard  and  for  which 
we  can  positively  and  irrefutably  validate  by 
records  from  two  University  Hospitals.  This 
patient  erroneously  assumed  that  her  amenor- 
rhea was  a sign  that  she  was  "going  through  the 
change  of  life".  She  had  no  idea  of  the  date  of 
her  last  menstrual  period  as  she  had  long  ceased 
to  pay  heed  to  them  for  her  sterilization  proce- 
dure had  held  her  in  good  stead  for  23  years. 
One  never  knows,  and  if  one  does,  can  one  ever 
really  be  sure? 

ACKNOWLEDGMENT 

Our  thanks  to  David  L.  Hemsell,  MD,  Professor 
of  Obstetrics  and  Gynecology,  University  of 
Texas,  Southwestern  Health  Science  Center,  for 
providing  confirmatory  historical  data. 

REFERENCE 

1.  Peterson  HB,  Zhisen  X,  Hughes  JM,  et  al.  The  risk 
of  ectopic  pregnancy  after  tubal  sterilization.  N Engl 
J Med  1997;336:762-767. 


Dr  Huddleston  is  an  associate  professor  of 
Clinical  Obstetrics  and  Gynecology , 
Department  of  Obstetrics  and  Gynecology, 
LSU  Health  Sciences  Center,  Shreveport,  Louisiana. 

Dr  Dunnihoo,  now  deceased,  was  the  former 
Professor  and  Vice-Chairman, 
Department  of  Obstetrics  and  Gynecology, 
Professor  of  Family  Medicine  and  Comprehensive  Care, 
LSU  Health  Sciences  Center,  Shreveport,  Louisiana. 


428  J La  State  Med  Soc  VOL  152  September  2000 


Mediation  in  Medical  Liability  Litigation 


Richard  A.  Spector,  MD 


Physicians  do  high-risk  work.  The  process 
of  investigation,  decision-making,  and 
treatment  exposes  the  physician  and  pa- 
tient to  uncertainties  rich  for  error.  Mistakes  are 
made  that  harm  patients.  Some  mistakes  meet 
the  legal  definition  of  medical  negligence. 

When  medical  negligence  has  occurred, 
fewer  than  10%  of  patients  who  have  legitimate 
claims  will  file  lawsuits.  Yet  over  40%  of  the 
claims  that  are  filed  are  frivolous.1  For  many 
patients,  the  legal  system  fails  to  provide  ad- 
equate access,  or  equitable  compensation,  for 
medical  injuries.  Of  those  who  seek  legal  ad- 
vice, many  with  minimal  injury  will  not  find 
attorneys  who  are  willing  to  accept  their  case 
because  of  the  high  costs  of  litigation.  Of  the 


claims  that  settle  or  are  adjudicated,  the  smaller 
claims  rarely  receive  compensation  commensu- 
rate with  the  damages  incurred.2 

In  response  to  the  rising  costs  of  medical  li- 
ability insurance  coverage  and  increased  num- 
bers of  suits,  nearly  every  state  has  attempted 
some  form  of  "tort  reform"  aimed  at  improving 
the  process  of  medical  liability  litigation.  Para- 
mount to  the  process  are  efforts  to  identify  or 
dismiss  non-meritorious  litigation,  provide  a 
framework  in  which  voluntary  settlement  nego- 
tiations can  operate,  and  provide  adjudication 
of  non-settled  claims.3 

Statutorily  mandated  medical  malpractice 
mediation  programs  have  been  established  in 
several  states.  The  panels  in  Michigan  and  Wis- 


J La  State  Med  Soc  VOL  152  September  2000  429 


consin  bear  little  resemblance  to  what  the  dis- 
pute resolution  community  defines  as  media- 
tion. Like  their  Louisiana  counterpart,  these  pan- 
els are  medical  malpractice  pretrial  screening 
panels. 

In  Michigan,  the  statute  requires  that  a panel 
be  convened  within  91  days  of  filing.4  The  panel 
is  composed  of  two  health  care  providers  cho- 
sen by  the  plaintiff  and  defendant,  respectively, 
and  three  attorneys  chosen  by  the  state.5  The 
defense  and  plaintiff  attorneys  present  briefs  and 
oral  arguments.  Their  clients  are  not  expected 
to  attend.  The  panel  renders  a judgment  and 
settlement  value  of  the  case.  The  opinion  of  the 
panel  is  not  binding,  except  for  the  judgment  of 
"frivolous",  when  the  plaintiff  must  post  cash 
or  surety  bond  in  the  event  that  he  loses  at  trial.6 
The  short  period  between  filing  and  panel  pre- 
vents adequate  discovery  for  any  member  of  the 
process  to  establish  a knowledgeable  base  ad- 
equate to  assess  the  merits  of  the  suit. 

Wisconsin's  procedure,  while  different  in 
form,  is  similar  in  its  failure  to  mediate  or  facili- 
tate any  closure.7  The  governor  appoints  the 
three-member  panel  composed  of  an  attorney,  a 
health  care  provider,  and  a layman.  The  "me- 
diation" is  a prerequisite  to  filing  a lawsuit.  The 
parties  are  present,  but  speak  through  their  at- 
torneys, unless  encouraged  to  participate  by  the 
panel  members.  The  panel  meets  to  encourage 
a compromise,  but  the  panel  has  no  authority  to 
render  a decision.  Nor  is  the  panel  result  binding. 
The  Wisconsin  panels  rarely  reach  a settlement.8 

The  Louisiana  pretrial  medical  screening 
panel9  differs  from  Michigan  and  Wisconsin  in 
that  the  panel  is  not  obligated  to  meet  for  12-18 
months  after  a complaint  is  lodged  with  the  Pa- 
tient Compensation  Fund.10  Unlike  the  Michi- 
gan and  Wisconsin  statutes,  Louisiana  leaves 
time  for  adequate  discovery.  The  parties  choose 
the  attorney  chairman  of  the  panel  from  a state 
pool  using  a strike  process.  The  defense  and 
plaintiff,  respectively,  choose  two  health  care 
providers.  The  two  health  care  providers  choose 
a third  health  care  provider.  The  parties  supply 
position  statements  accompanied  by  relevant 


medical  records.  They  may  include  copies  of 
depositions  and  expert  testimony.  The  panel  ren- 
ders an  opinion  regarding  departure  from  the 
standards  of  care  and  causation.  The  parties  may 
meet  with  the  panel  and  question  panel  mem- 
bers regarding  the  opinion.  The  panel  decision 
is  not  binding.  If  the  panel  decision  fails  to  help 
resolve  the  dispute,  then  the  plaintiff  may  pro- 
ceed to  file  a lawsuit  within  90  days  of  the  panel 
decision.  The  panel  members  may  be  subpoe- 
naed to  testify  at  trial.  Criticism  of  the  Louisi- 
ana Review  Panel  is  similar  to  that  encountered 
in  Alaska.11  In  rural  areas,  close  knit  physician 
relationships  tend  to  create  protectionism,  bias- 
ing the  panel  in  favor  of  the  defendant.12 

In  1991,  North  Carolina  adopted  a trial  pro- 
gram of  mediated  settlement  conferences  for  all 
civil  cases  involving  claims  of  greater  than 
$10,000.  This  included  virtually  all  medical  mal- 
practice cases.  The  parties  may  select  their  own 
mediator;  the  mediation  may  occur  at  any  time 
the  parties  feel  that  their  case  is  ripe  for  the  pro- 
cess, as  long  as  the  mediation  occurs  prior  to 
trial;  the  parties  and  their  attorneys  must  attend; 
an  insurer  with  full  authority  to  settle  must  at- 
tend; and  the  session  follows  the  standard  me- 
diation format  of  opening  session,  followed  by 
caucus.13  When  the  trial  program  proved  suc- 
cessful, the  General  Assembly  of  North  Caro- 
lina authorized  all  judicial  districts  to  implement 
mediated  settlement  conferences  in  superior 
court  civil  actions.14 

Between  1992  and  1995,  318  medical  liabil- 
ity cases  were  sent  to  mediation.15  Of  this  group, 
one  quarter  were  dismissed  by  the  parties  prior 
to  mediation.  Reviewing  data  obtained  from  the 
cases  that  went  to  mediations,  Metzloff  reported 
the  following  observations.  Ninety-four  percent 
of  the  mediations  involved  a single  session.  The 
mean  and  median  length  of  mediations  was  3.7 
hours  and  3.3  hours,  respectively.  Twenty-five 
percent  of  the  cases  resolved  at  the  mediation 
conference.  An  equal  percentage  resolved  within 
6 months  of  the  mediation.  Of  the  remaining 
cases,  half  settled  or  were  dismissed  beyond  six 
months  from  the  mediation,  and  the  rest  went 


430  J La  State  Med  Soc  VOL  152  September  2000 


to  trial.  Of  the  group  that  went  to  trial,  83.3% 
resolved  in  favor  of  the  defendant.  This  repre- 
sents an  overall  trial  rate  of  13.2%,  not  signifi- 
cantly different  from  the  pre-mediation  era. 

Half  of  the  mediators  expressed  an  opinion 
regarding  settlement  offers,  with  40%  to  45% 
exploring  risks  of  litigation,  strengths  of  the  case, 
and  likely  jury  verdicts.  Though  present  in  all 
the  mediations,  plaintiffs  did  not  participate  in 
the  mediation  in  15%  of  the  sessions.  In  a third 
of  the  sessions,  the  plaintiffs  were  actively  in- 
volved with  the  mediator.  The  defendant  phy- 
sician was  absent  22%  of  the  time.  When  present, 
the  physician  was  uninvolved  in  the  mediation 
half  of  the  time.  The  average  cost  of  the  media- 
tion was  $520,  with  each  side  spending  an  aver- 
age of  10  hours  in  connection  with  the  media- 
tion. 

Post-mediation  interviews  with  the  partici- 
pating attorneys  revealed  an  interesting  set  of 
observations.  Seventy-five  percent  indicated  that 
all  malpractice  cases  should  be  referred  to  me- 
diation. Reasons  cited  included  the  length  and 
expenses  associated  with  the  adversarial  pro- 
cess, the  personal  benefits  that  accrue  to  the  liti- 
gating parties  (healing  process  for  both  parties), 
and  the  opportunity  to  resolve  cases  efficiently 
when  liability  was  not  contested. 

When  queried  about  the  mediator's  role,  al- 
most 70%  of  the  attorneys  placed  value  on  me- 
diator opinions  about  aspects  of  the  case.  How- 
ever, most  felt  that  such  evaluative  statements 
should  remain  within  the  private  caucus.  Only 
one  third  of  the  attorneys  felt  that  the  mediator 
should  have  malpractice  litigation  or  medical 
expertise.16 

Much  of  the  North  Carolina  experience  ech- 
oes through  the  Rush-Presbyterian-St.  Luke 
Medical  Center  initiative.17  Working  to  establish 
a mediation  program  for  Rush's  medical  center, 
retired  Cook  County  judge,  Jerome  Lerner,  noted 
that  the  majority  of  medical  liability  trial  attor- 
neys were  unfamiliar  with  mediation.  Yet,  when 
approached  about  a mediation  program,  most 
were  receptive  to  the  option.  Rush  tapped  re- 
tired judges  and  seasoned  trial  lawyers  to  me- 
diate. They  used  a co-mediator  format  to  bal- 


ance any  perception  of  mediator  bias.  Between 
autumn  1995  and  the  time  of  publication  of  his 
report,  82.4%  of  seventeen  mediations  resulted 
in  resolution.  The  average  duration  of  the  me- 
diation was  3 hours.  The  program  generated 
such  a positive  response  in  the  medical  liability 
bar  that  other  hospitals,  insurers,  and  attorneys 
have  sought  instruction  from  the  Rush  media- 
tor group. 

THESIS 

Would  mediation  work  in  Louisiana's  pre-trial 
screening  panel  and  two-tiered  insurance  system? 

METHOD 

In  an  effort  to  answer  this  question,  the  author 
created  a questionnaire  (Table).  Six  prominent 
attorneys  were  interviewed.18  Each  attorney  de- 
votes greater  than  three  quarters  of  his/her  pro- 
fessional career  to  medical  liability  litigation. 
Each  has  greater  than  10  years  experience  in  this 
field.  Each  attorney  has  mediated  medical  liabil- 
ity cases.  Three  are  defense  attorneys,  three  are 
plaintiff  attorneys.  Each  interview  lasted  be- 
tween VA  and  2 hours. 

RESULTS 

The  plaintiff  attorney  group  had  mediated  two 
to  three  medical  liability  cases  each.  Two  of  the 
defendant  group  had  mediated  six  each;  one  had 
mediated  fifteen  cases.  Of  the  33  cases  that  made 
up  their  experience,  31  (93%)  resolved  at  media- 
tion or  within  2 months  of  mediation. 

Both  sides  of  the  bar  felt  that  cases  involving 
institutions  where  an  individual  health  care  pro- 
vider has  not  been  named  were  easier  to  settle. 
These  cases  involve  simple  dollar  issues  and 
exclude  concerns  that  physicians  have  regard- 
ing National  Data  Bank  reporting.19 

When  discussing  the  benefits  of  mediation 
if  the  case  resolved,  two  plaintiff  attorneys  ex- 
pressed that  their  client's  need  for  privacy  was 
preserved.  None  saw  major  drawbacks  if  me- 
diation resolved  the  case.  In  fact,  one  plaintiff 
attorney  felt  that  settlements  were  pretty  close 


J La  State  Med  Soc  VOL  152  September  2000  431 


to  pre-mediation  assessment  of  the  case  value. 

The  major  drawback  to  a failed  mediation  is 
the  disclosure  of  facts  and  strategies.  All  parties 
felt  that  opposing  counsels  generally  were  well 
educated  and  savvy  enough  that  discovery  at 
mediation  would  have  little  impact  at  trial.  Most 
felt  that  the  opportunity  to  weigh  the  emotional 
impact  of  a case,  educate  the  client,  and  gain  a 
clearer  understanding  of  the  strengths  and  weak- 
nesses of  the  case  far  exceeded  the  drawbacks 
to  a failed  mediation. 

Factors  that  portend  an  unsuccessful  media- 
tion included  timing.  Both  plaintiff  and  defense 
felt  that  a poorly  developed  case  was  not  ripe 
for  mediation.  Yet  one  defense  counsel  has  had 
23  years  of  a unique  approach  to  resolution.  On 
multiple  occasions,  he  has  brought  physician, 
patient,  and  plaintiff  counsel  together  prior  to 
panel  formation.  With  sharing  of  data  and  clear 
communication,  many  of  these  early  meetings 
resulted  in  dismissal  or  settlement.  On  at  least 
one  occasion,  the  patient  asked  to  return  to  the 
physician's  care. 

Two  thirds  of  the  attorneys  felt  that  the  an- 
gry plaintiff  who  demands  public  resolution  is 
a poor  mediation  choice.  Yet,  two  of  these  attor- 
neys recognized  the  need  to  educate  unreason- 
able clients  as  a variable  that  lent  itself  to  suc- 
cessful mediation. 

When  the  mediation  includes  the  physician 
and  liability  is  in  question,  both  sides  of  the  bar 
felt  that  mediation  was  apt  to  fail.  Mediation's 
best  chance  was  in  the  circumstance  where  li- 
ability was  not  in  question  or  where  there  were 
multiple  defendants.  In  the  case  of  multiple  de- 
fendants, mediation  improves  their  communi- 
cation allowing  them  to  confront  their  propor- 
tionate liability. 

The  overwhelming  perspective  for  success 
was  the  willingness  of  the  parties  to  meet  and 
resolve  the  issues.  Even  when  there  exist  per- 
sonality conflicts  between  the  attorneys,  it  was 
expressed  that  a good  mediator  could  side  step 
the  attorneys  to  bring  the  parties  together.  Criti- 
cal to  resolution  was  the  presence  of  the  insurer 
with  authority  to  settle.  In  Louisiana,  this  means 
both  the  private  insurer  for  the  first  $100,000  of 


coverage,  as  well  as  a representative  of  the  Pa- 
tient Compensation  Fund. 

One  opinion  expressed  in  favor  of  mediation 
was  in  cases  where  the  attorneys  disagreed  on 
an  issue  of  law.  Here,  the  experience  of  the  me- 
diator was  critical.  In  a related  example,  trial 
with  adjudication  supporting  or  reversing  old 
law  might  be  harmful  to  both  sides  of  the  bar.20 
Mediated  settlements  leave  the  status  quo  in 
place  to  the  benefit  of  both  parties. 

One  plaintiff  attorney  stated  that  he  would 
mediate  any  case,  seeing  only  potential  benefit 
to  bringing  the  parties  together. 

All  the  attorneys  preferred  a mediator  who 
is  an  attorney  with  trial  experience.  None  felt 
that  medical  liability  experience  was  a prereq- 
uisite to  good  mediation  skills.  All  of  the  defense 
attorneys  were  comfortable  with  evaluative 
mediator  statements.  Their  comments  included: 
"inexpensive  third  party  assessment";  "don't 
they  always?";  and  "needed  to  inflict  a third 
party's  reality".  The  defense  group  was  unani- 
mous that  evaluative  comments  should  be  made 
in  private  so  that  comments  about  the  strengths 
or  weaknesses  of  their  case  did  not  violate  privi- 
lege. One  defense  attorney  did  not  want  a purely 
facilitative  mediator. 

One  plaintiff  attorney  felt  that  honest  com- 
ment was  welcome  but  remained  sensitive  to 
any  telltale  signs  of  bias.  The  other  plaintiff  at- 
torneys were  adamant  that  any  perception  of 
bias  would  compromise  the  outcome  of  the  me- 
diation. They  felt  that  their  reception  of  comment 
depended  on  the  experience  and  neutrality  of 
the  mediator.  They  were  more  apt  to  accept  com- 
ment late  in  the  day  if  there  are  issues  of  liabil- 
ity or  causation  that  are  contested  and  that  such 
comment  might  be  crucial  to  resolving  an  im- 
passe. The  plaintiff  group  seemed  to  favor  the 
facilitative  mediator  who  was  willing  to  make 
evaluative  comments,  in  private,  late  in  the  day, 
at  impasse.  To  control  for  the  perception  of  bias, 
one  defense  attorney  prefers  that  the  plaintiff 
choose  the  mediator. 

Five  of  the  attorneys  felt  that  the  defendant 
physician  should  be  present  at  the  mediation.  If 
the  personality  is  inflammatory,  they  recognize 


432  J La  State  Med  Soc  VOL  152  September  2000 


that  physician  presence  may  be  an  impediment. 
However,  absence  of  the  health  care  provider 
doesn't  help  resolve  the  plaintiff's  need  to  ad- 
dress the  interpersonal  issues  often  present  be- 
tween the  patient  and  physician. 

There  was  unanimous  opinion  for  the 
plaintiff's  presence,  with  special  recognition  that 
the  "motivating  party"  is  present.  This  may  be 
the  spouse,  parent,  or  child  of  the  injured  pa- 
tient. All  recognized  that  resolution  includes 
some  education  of  and  venting  by  the  aggrieved 
party.  Absent  this,  mediation  is  "nothing  more 
than  dickering  over  dollars. . .and  is  humiliating 
to  the  plaintiff". 

All  of  the  mediations  were  caucus  style,  with 
only  one  plaintiff  attorney  expressing  a dislike 
for  the  isolation.  Most  felt  that  separating  the 
parties  helped  diffuse  the  emotions  and  confron- 
tational aspects  of  negotiation.  Most  felt  that  this 
separation  was  the  hallmark  that  allowed  the 
mediator  to  bring  the  parties  closer  together. 

The  mediations  lasted  from  4 to  8 hours,  with 
most  lasting  6 hours.  No  party  returned  for  a 
second  mediation.  Those  mediations  that  did  not 
resolve  at  mediation,  but  which  settled  as  a re- 
sult of  the  mediation,  did  so  within  2 months. 

On  two  occasions,  open-ended  conversation 
returned  to  Louisiana's  medical  review  panel. 
One  plaintiff  attorney  expressed  the  opinion  that 
New  Orleans  metropolitan  area  panels  were  less 
prone  to  defense  bias  than  rural  Louisiana.  He 
suspected  that  10%  to  15%  of  his  panels  favored 
the  plaintiff.  This  corresponds  to  the  10%  that 
are  traditionally  adjudicated  at  trial.21 

One  defense  attorney  felt  that  the  medical 
review  panel  favored  the  plaintiff.  He  noted  that 
a pro-plaintiff  panel  affords  the  plaintiff  with 
three  local  expert  witnesses  for  trial.  Because  of 
this,  pro-plaintiff  panels  result  in  settlement. 
When  settlement  negotiations  fail,  it  is  difficult 
for  the  defendant  to  prevail  at  trial.  Furthermore, 
a pro-defense  panel  does  not  limit  the  plaintiff's 
ability  to  proceed  to  trial. 

Interestingly,  most  of  the  attorneys  felt  that 
mediation  would  be  most  effective  after  the 
panel  met.  They  based  this  on  the  slow  discov- 


ery process,  feeling  that  a case  rarely  ripened 
into  a negotiation  stage  prior  to  panel  findings. 

CONCLUSION 

Metropolitan  New  Orleans  litigators  have  vary- 
ing degrees  of  exposure  to  mediation  as  a tool 
to  resolve  medical  liability  lawsuits.  Unlike 
North  Carolina,  all  of  the  experience  is  volun- 
tary. Both  the  Rush  experience  and  New  Orleans 
reflect  a significantly  higher  percentage  of  me- 
diated resolution  than  North  Carolina.  This 
probably  is  due  to  the  natural  selection  associ- 
ated with  voluntary  participation,  as  well  as  the 
longer  time  to  assess  cases  prior  to  mediation. 

Louisiana's  unique  screening  process  and 
two-tiered  insurance  coverage  does  not  seem  to 
affect  decisions  regarding  mediation,  other  than 
needing  the  insurers  present  at  the  mediation. 
Both  sides  tend  to  view  the  panel  as  another 
hoop  through  which  to  jump,  rather  than  as  a 
benefit  to  the  process.  This  is  true  especially  for 
the  plaintiff's  bar,  though  some  defense  attor- 
neys view  the  panel  as  potentially  beneficial  to 
the  plaintiff. 

The  greatest  differences  in  opinion  relate  to 
the  evaluative  role  of  the  mediator,  with  the 
plaintiff  attorneys  far  more  suspicious  of  bias 
than  the  defense  attorneys.  Overall,  both  sides 
of  the  bar  view  mediation  with  cautious  enthu- 
siasm. They  see  mediation  as  a means  to  resolve 
cases  that  have  not  responded  to  negotiated 
settlement.  Certainly  the  degree  of  success  re- 
flects both  a wise  choice  of  cases  to  mediate  as 
well  as  significant  attorney  cooperation.  The 
perception  that  mediated  settlements  come  close 
to  attorney  assessment  of  case  value  suggests 
that  mediation  can  offer  significant  savings  in 
time,  money,  and  emotional  distress  for  both 
parties. 

While  the  sampling  for  attorney  interviews 
is  small  and  restricted  to  an  area  of  Louisiana 
with  high  population  density,  the  results  of  this 
study  should  serve  as  testimony  to  mediation 
as  an  alternative  means  to  resolve  medical  liabil- 
ity litigation. 


J La  State  Med  Soc  VOL  152  September  2000  433 


TABLE.  Mediation  in  Medical  Liability  Litigation 


1.  Have  you  used  mediation  to  resolve  medical  malpractice  litigation  cases? 

a.  If  so,  approximately  how  many  cases? 

b.  Types  of  cases: 

i.  Liability  not  disputed 

ii.  Individual  where  PCF  involved 

iii.  Institution  without  cap 

2.  Does  mediation  lend  itself  differently  to  the  above  cases? 

a.  Discuss  the  benefits  and  drawbacks  to  mediation  if  the  case  resolves. 

b.  Discuss  the  benefits  and  drawbacks  to  mediation  if  there  is  no  resolution. 

3.  What  percentage  of  cases  have  settled? 

a.  Individual 

i.  At  mediation 

ii.  As  a result  of  mediation 

b.  Institution 

i.  At  mediation 

ii.  As  a result  of  mediation 

4.  Name  three  to  five  variables  critical  to  successful  mediation  (i.e.,  necessary  to  anticipate  a 
successful  mediation). 

5.  Name  three  to  five  variables  whose  presence  portends  an  unsuccessful  mediation. 

6.  How  do  you  choose  a medical  malpractice  mediator? 

7.  Do  you  want  the  mediator  to  comment  RE: 

a.  Strength  of  the  case  (and  why) 

b.  Value  of  the  case  (and  why) 

8.  Do  you  perceive  that  there  are  specific  benefits  or  drawbacks  to: 

a.  Mediator  style 

b.  Presence  or  absence  of  the 

i.  Defendant 

ii.  Plaintiff 

iii.  Insurer  with  authority  to  settle  sum 

c.  Number  and/ or  length  of  mediation(s) 

d.  Structure  of  mediation  (open  v.  caucus) 

9.  Additional  comments 


434  J La  State  Med  Soc  VOL  152  September  2000 


REFERENCES 

1.  Thomas  B.  Metzloff,  The  Unrealized  Potential  of 
Malpractice  Arbitration,  31  Wake  Forest  L.  Rev.  203, 
204,  1996  (reporting  results  from  Henry  S.  Farber 
& Michelle  J.  White,  Medical  Malpractice:  An 
Empirical  Examination  of  the  Litigation  Process,  22 
Rand  J.  Econ.  199  206  tbl.2  (1991)). 

2.  Catherine  S.  Meschievitz,  Efficacious  or  Precarious? 
Comments  on  the  Processing  and  Resolution  of  Medical 
Malpractice  Claims  in  the  United  States,  3 Annals 
Health  L.  123, 127-130  (1994)  (summarizing  results 
of  Harvard  Medical  Practice  Study  Group,  Patients, 
Doctors  and  Lawyers:  Medical  Injury,  Malpractice 
Litigation  and  Patient  Compensation  in  New  York 
(1990);  Frank  Sloan  et  al..  Suing  for  Medical 
Malpractice  (1993)). 

3.  Thomas  B.  Metzloff,  Alternate  Dispute  Resolution 
Strategies  in  Medical  Malpractice.  9 Alaska  L.  Rev. 
429,  431  (1992). 

4.  Mich.  Comp.  Laws.  Ann.  600.4903  (1998). 

5.  Mich.  Comp.  Laws.  Ann.  600.4905  (1998). 

6.  Sheila  M.  Johnson,  A Medical  Malpractice  Litigator 
Proposes  Mediation,  52  SPG.  Disp.  Resol.  J.  42,  46 
(1997). 

7.  Id.  at  46. 

8.  Id. 

9.  La.  R.S.  Ann.  40:  1299.47  (1998). 

10.  La.  R.S.  Ann.  40:  1299.42  (1998). 

11.  9 Alaska  L.  Rev.  429  at  453. 

12.  Louisiana  Trial  Lawyers  Association,  1993.  (The 
author  was  a panelist  at  the  New  Orleans  Section 
meeting.) 

13.  Thomas  B.  Metzloff,  et.  al..  Empirical  Perspectives 
on  Mediation  and  Malpractice.  60-WTR  Law  & 
Contemp.  Probs.  107,  110-113  (1997). 

14.  N.C.  Gen.  Stat.  § 7A-38.1  (1998). 

15.  60-WTR  Law  & Contemp.  Probs.  104. 

16.  Id. 

17.  Jerome  Lerner,  The  Rush  Initiative  for  Mediation  of 
Medical  Malpractice  Claims.  11  CBA  Record  40 
(1997). 

18.  Listed  in  alphabetical  order: 

C.  Wm.  Bradley,  Jr.,  601  Poydras  Street, 
New  Orleans,  LA 

Robert  J.  David,  1100  Poydras  Street, 
New  Orleans,  LA 

Deborah  E.  Lavender,  210  Baronne  Street, 
New  Orleans,  LA 

Edward  J.  Rice,  Jr.,  One  Shell  Square, 
New  Orleans,  LA 

Richard  A.  Thompson,  210  Baronne  Street, 
New  Orleans,  LA 

Cristina  R.  Wheat,  One  Shell  Square, 
New  Orleans,  LA 


19.  42  U.S.C.  §§  11101,  11131  (Health  Care  Quality 
Improvement  Act). 

20.  e.g.  Strict  liability  in  transfusion  transmission  of 
Hepatitis  C. 

21.  9 Alaska  L.  Rev.  at  433. 


Dr  Spector  has  a private  practice  for  Otolaryngology 
located  in  New  Orleans,  Louisiana.  He  is  a clinical 
instructor  in  the  Department  of  Otolaryngology-Head  & 
Neck  Surgery  at  Tulane  School  of  Medicine  in  New 
Orleans,  Louisiana.  Dr  Spector  is  currently  in  his  final 
year  at  the  Loyola  University  Law  School. 


J La  State  Med  Soc  VOL  152  September  2000  435 


The  Internet  for  Louisiana  Physicians 


Michael  S.  Ellis,  MD 


Fewer  than  50%  of  Louisiana  physicians  actively  use  the  Internet,  and  many  of  them  confine 
their  usage  to  e-mailing  among  family  and  friends.  The  purpose  of  this  article  is  to  acquaint 
the  reader  with  many  of  the  benefits  of  exploiting  the  incredible  potential  of  this  technologi- 
cal invention.  I provide  addresses  and  information  about  sites  that  I believe  warrant  usage  by 
our  colleagues.  Of  the  vast  smorgasbord  of  data  available  we  highlight  educational  Web  sites 
for  professionals  and  the  public,  how  to  determine  credibility  of  information,  clinical  research 
of  scientific  articles,  computer  security,  federal  and  state  government  sites,  newspapers,  politi- 
cal and  socioeconomic  functions,  medical  supply  shops,  e-mail  and  other  computerized  com- 
munication, electronic  medical  records,  personal  or  professional  Web  sites,  and  future  medi- 
cal internet  uses.  It  is  hoped  that  this  process  will  encourage  nonparticipating  colleagues  to 
begin  using  this  modality  while  also  supplying  sites  that  current  users  may  not  yet  have  dis- 
covered. 


It  is  becoming  of  critical  importance  for  phy- 
sicians to  use  the  Internet,  and  yet  less  than 
50%  of  us  actively  use  it.  By  pointing  out  po- 
tential uses  and  easing  the  process  of  finding 
useful  Web  sites,  this  article  may  stimulate  inter- 
est for  some  of  the  other  half  to  begin  exploring 
the  Internet.  Avoiding  incorporating  the  Internet 
into  our  medical  usage  would  be  akin  to  not  ac- 
knowledging the  usefulness  of  the  telephone, 
FAX  machines,  copiers,  and  calculators. 

It  took  30  years  for  100  million  TVs  to  be  in 
use  in  the  United  States,  but  only  5 years  to 
achieve  100  million  Internet  users.  While  our  citi- 
zens use  the  Internet  for  many  reasons,  70%  use 
it  for  health  information.  Health  products  and 
pharmaceuticals  are  being  advertised  and  sold 


online  to  consumers.  Some  Web  sites  even  sched- 
ule real  doctors  online  to  type,  talk,  or  even  digi- 
tally view  patients  in  an  interactive  fashion. 

Medicine  exerts  enormous  demands  on  our 
time  in  so  many  ways,  including  our  efforts  to 
"keep  up"  with  the  vast  information  explosion 
in  all  of  our  fields.  If  we  can  have  easy  access  to 
information,  this  should  be  of  immense  benefit 
to  our  practices. 

The  capabilities  that  the  Internet  immedi- 
ately unleashes  are  boundless  for  all  facets  of 
life.  Amazingly,  the  Internet  may  even  speed  the 
demise  of  managed  care  as  it  has  so  many  other 
middlemen.  Already  some  consumers,  operat- 
ing over  the  "Net"  through  corporate  buying 
groups,  are  buying  services  from  groups  of  doc- 


436  J La  State  Med  Soc  VOL  152  September  2000 


tors  and  hospitals.  They  are  negotiating  on  the 
basis  of  price,  credentials,  and  quality  ratings, 
with  coverage  customized  across  different 
plans.1 

For  those  with  "zero"  experience,  I recom- 
mend a brief  Internet  course  or  time  spent  with 
your  children  (of  any  age),  all  of  whom  are  be- 
coming educated  in  this  marvelous  learning 
modality.  For  anyone  desiring  to  peruse  a "dic- 
tionary" of  Internet  terms,  go  to  "Learning  a New 
Language:  Conversational  Internet". 

http:  / / www.texmed.org/liy/ 
internet_glossary.  asp 

The  Internet  is  composed  of  a massive  world- 
wide network  of  computers,  which  are  capable 
of  interconnection.  The  Internet  enables  files  to 
be  transferred  among  all  these  computers,  re- 
mote login,  electronic  mail,  news  transfer  by 
typed  pages,  photos  or  graphics,  video,  and  au- 
dio. In  this  article,  I will  be  providing  a large 
number  of  Internet  or  World  Wide  Web  (WWW) 
addresses,  which  are  known  as  Universal  Re- 
source Locators  (URLs).  These  addresses  repre- 
sent links  to  network  services.  The  first  part  of 
the  URL  (before  the  two  slashes)  specifies  the 
method  of  access.  The  second  is  typically  the 
address  of  the  computer  being  sought.  Further 
parts  may  specify  the  names  of  files,  the  port  to 
connect  to,  or  the  text  to  search  for  in  a data- 
base. A URL  is  always  a line  with  no  spaces. 

A basic  understanding  of  simple  Internet  use 
is  assumed.  You  must  have  access  to  an  Internet 
Service  Provider  (ISP),  such  as  AOL,  Microsoft 
Internet  Explorer,  Netscape  Communicator, 
Prodigy,  CompuServe,  or  AT&T  World  Net. 
Once  "on  line"  with  one  of  these  providers, 
should  you  wish  to  visit  a referenced  site,  you 
need  only  type  the  Internet  address  (http  or 
www)  into  the  action  site  and  hit  ENTER  to  be 
conveyed  to  that  site.  From  there  you  can  jump 
to  all  of  that  Web  site's  "sub  sites".  You  can  then 
peruse  its  contents  and  "SAVE"  the  link  site  in 
an  appropriate  "folder"  category  in  your  "favor- 
ite places"  for  ease  in  later  revisiting  the  site. 

This  article  may  become  available  on  the 


LSMS  Web  site,  or  I will  be  pleased  to  "e-mail" 
it  to  any  interested  party,  to  enable  receipt  of  the 
suggested  addresses  in  "hyperlink"  (blue)  form 
for  immediate  connection,  rather  than  just  the 
Internet  "address".  To  access  that  Web  site,  you 
would  simply  click  on  the  supplied  URL  if  it 
appears  in  blue.  If  the  link  cannot  be  clicked  on, 
simply  cut  and  paste  (or  type)  the  desired  Web 
site  address  or  URL  into  your  browser's  "URL", 
"Location",  or  "Address"  box,  on  the  browser 
"tool  bar"  and  press  ENTER. 

I have  divided  my  recommended  links  by 
category,  which  is  the  way  I set  up  my  personal 
folders.  The  user  can  then  ignore  those  categories 
of  no  interest  or  view  those  of  possible  personal 
interest. 

LINKS  OF  GENERAL  INTEREST 

There  is  a wide  range  of  links  of  interest  to  phy- 
sicians, which  are  available  through  our  medi- 
cal societies  and  specialty  societies. 

National 

American  Medical  Association: 
http:/  / www.ama-assn.org 
American  College  of  Surgeons: 
http:/  / www.facs.org 

American  Academy  of  Otolaryngology-Head 
and  Neck  Surgery: 

http:/  / www.entnet.org 
American  College  of  Physicians-American 
Society  of  Internal  Medicine: 
http:  / / www.acponline.org 
Association  of  American  Physicians  and 
Surgeons: 

http:/  / www.aapsonline.org 

State 

Louisiana  State  Medical  Society: 
http:  / / www.lsms.org 

Medical  Association  of  the  State  of  Alabama: 
http:  / / www.masalink.org 
California  Medical  Association: 
http:  / / www.cmanet.org 
Texas  Medical  Association: 
http:/  / www.texmed.org 


J La  State  Med  Soc  VOL  152  September  2000  437 


LSU  Medical  Center: 

http:  / / www.lsumc.edu 
LSU  Medical  Center  E-mail  Directory: 

http:  / / www.lsuhsc.edu  / Email / default.htm 
Tulane  Medical  Center: 

http:  / / www.tmc.tulane.edu 
Louisiana  State  Board  of  Medical  Examiners: 
http:/  / www.lsbme.org 
LAMMICO: 

http:/  / www.lammico.com 
Louisiana  Psychiatric  Medical  Association: 
http:  / / www.lpma.net 

Parish 

Orleans  Parish  Medical  Society: 
http:  / / www.opms.org 
East  Baton  Rouge  Parish  Medical  Society: 
http:  / / www.ebrpms.org 
Lafayette  Parish  Medical  Society: 
http:  / / www.lpms.org 

The  Little  Blue  Book,  which  is  distributed  in  145 
metropolitan  editions  to  over  275,000  physicians. 
It  is  used  in  doctor's  offices  for  local,  up-to-date 
listing  of  physicians. 

http:  / / www.thelittlebluebook.com 
Other  medical  links  provided  by  the  AMA  can 
be  found  at: 

http:  / / www.vfed.org:8080/ public/ 
soclinks.htm 

Medical  Journals 

List  of  all  medical  specialty  On-line  Journals: 
http:  / / uhs.bsd.uchicago.edu/  -dliebovi/ 
jjournals.html 

Treadwell  Library  at  Massachusetts  General 
Hospital: 

http:  / / www.mgh.harvard.edu/library/ 
electron.htm 

Journal  of  the  American  Medical  Association: 
http:  / / jama. ama-assn.org 
New  England  Journal  of  Medicine: 
http:  / / www.nejm.org 
British  Medical  Journal: 
http:  / / www.bmj.com 
Annals  of  Internal  Medicine: 

http:  / / www.acponline.org/journals/ 
annals  / annaltoc.htm 


Archives  of  Family  Medicine: 
http:  / / archfami.ama-assn.org 
Archives  of  Pediatrics: 

http:  / / archpedi.ama-assn.org 
Archives  of  Surgery: 

http:  / / archsurg.ama-assn.org 
American  College  of  Surgeons  On-line  Library: 
http:  / / www.facs.org/  fellows_mfo/ 
library.html 

Journal  of  the  American  Academy  of  Orthopedic 
Surgeons: 

http:  / / www.jaaos.org 
Online  Journal  of  Cardiology: 

http:  / / www.mmip.mcgill.ca/heart/ 
index.html 

Archives  of  Otolaryngology-Head  and  Neck 
Surgery: 

http:  / / archotol.ama-assn.org 
American  Academy  of  Allergy,  Asthma  and 
Immunology  Online: 
http:  / / www.aaaai.org 

SCIENTIFIC  ARTICLES 

There  is  a wide  range  of  Web  sites  designed  with 
"search  engines"  to  ease  locating  of  articles  by 
topic.  There  are  some  that  have  "specialty  spe- 
cific" subcategories  for  perusing  of  articles  of 
interest  to  specific  fields.  The  articles  can  then 
be  printed  for  "hard  copy"  storage  or  "down- 
loaded" for  saving  on  the  computer  for  other 
uses.  The  field  is  changing  and  other  sites  are 
introduced  daily,  which  makes  any  effort  for 
comprehensive  coverage  impossible.  Neverthe- 
less, one  must  begin  somewhere  and  this  effort 
can  be  of  immense  value,  particularly  to  the  neo- 
phyte. 

The  National  Library  of  Medicine  (NLM) 
produces  and  publishes  the  Index  Medicus,  a 
comprehensive  monthly  listing  of  articles  ap- 
pearing in  the  world's  leading  medical  journals. 
The  Library  also  operates  a computerized  Index 
Medicus,  known  as  MEDLINE,  and  has  pio- 
neered the  introduction  of  large  medical  biblio- 
graphic databases. 

http:  / / www.nlm.nih.gov 
http:  / / www.nlm.nih. gov/ databases/ 
medline.html 


438  J La  State  Med  Soc  VOL  152  September  2000 


With  most  of  its  articles  written  for  health 
professionals,  MEDLINE  is  the  NLM's  premier 
bibliographic  database  covering  the  fields  of 
medicine,  nursing,  dentistry,  veterinary 
medicine,  and  the  preclinical  sciences.  It  contains 
an  index  to  the  world's  most  extensive  collection 
of  published  medical  information.  Essentially  all 
of  the  scientific  journal  articles  are  indexed  for 
MEDLINE.  Their  citations  are  searchable;  using 
NLM's  controlled  vocabulary,  MeSH  (Medical 
Subject  Headings).  MEDLINE  contains  all  of  the 
citations,  which  are  published  in  Index  Medicus, 
and  it  corresponds  in  part  to  the  International 
Nursing  Index  and  the  Index  to  Dental  Literature. 
It  provides  articles  from  more  than  3,800 
international  biomedical  journals. 

PubMed  is  the  NLM's  search  service  that 
provides  access  to  over  11  million  citations  in 
MEDLINE,  PreMEDLINE,  and  other  related 
databases,  with  links  to  participating  online  jour- 
nals. 

http : / / www.ncbi.nlm.nih.  go  v / PubMed 

PreMEDLINE  provides  basic  citation  infor- 
mation and  abstracts  before  the  records  are 
indexed  and  put  into  MEDLINE.  Once  the 
indexing  is  finished,  the  complete  records  are 
added  to  the  weekly  MEDLINE  update.  The 
PreMEDLINE  record  is  then  deleted  from  the 
database.  Be  aware  that  PreMEDLINE  citations 
have  not  gone  through  the  NLM's  quality  control 
process. 

http:/  / www.nlm.nih.gov/pubs/factsheets/ 
onlinedatabases.html#premed 

The  full  resources  of  the  National  Library  of 
Medicine  are  available  through  Internet  Grateful 
Med.  This  site  will  do  a complete  bibliographic 
search  and  provide  abstracts  of  the  articles.  A 
companion  program  called  Loansome  Doc 
allows  users  to  order  full-text  copies  of  articles 
from  a local  medical  library  (local  fees  and 
delivery  methods  may  vary), 
http:  / / igm.nlm.nih.gov 
http:  / / tendon.nlm.nih.gov / Id  / 
loansome.html 


However,  the  full  text  of  articles  for  many  jour- 
nals are  available  FREE  via  a link  to  the 
publisher's  Web  site  from  PubMed.  If  you  see 
"Link  Out"  on  an  article  citation,  click  on  this 
feature  for  additional  options. 

http:/ / www.ncbi.nlm.nih.gov /PubMed 

The  Directory  of  Information  Resources  (DIR), 
from  the  NLM's  online  database,  focuses  prima- 
rily on  health  and  biomedical  information  re- 
sources including  organizations,  government 
agencies,  information  centers,  professional  so- 
cieties, voluntary  associations,  support  groups, 
academic  and  research  institutions,  and  research 
facilities.  Records  contain  resource  names,  ad- 
dresses, phone  numbers,  and  descriptions  of 
services,  publications,  and  holdings, 
http:  / / dirline.nlm.nih.gov 

The  Doctor's  Guide  is  intended  as  a comprehen- 
sive, personalized  Internet  resource  for  peer-re- 
viewed medical  news.  It  enables  the  creation  of 
a Web  "favorite  topics"  site. 

You  can  register  and  receive  the  Doctor's 
Guide  Personal  Edition,  which  provides  free  e- 
mail  updates  in  your  areas  of  interest,  as  well  as 
specialized  searches  and  other  resources.  It  pro- 
vides access  to  over  1000  peer-reviewed  journals 
and  can  create  links  to  your  favorite  journals  and 
sites. 

http:/  / www.docguide.com 

The  National  Institutes  of  Health  (NIH)  is  one 
of  the  world's  foremost  medical  research  centers 
and  the  Federal  focal  point  for  medical  research 
in  the  United  States.  Its  Web  site  has  medical 
news,  scientific  research,  health  information,  and 
grants  opportunities.  The  NIH  is  one  of  eight 
health  agencies  of  the  Public  Health  Service, 
which,  in  turn,  is  part  of  the  US  Department  of 
Health  and  Human  Services  (DHHS). 
http:  / / www.nih.gov 
http:  / / phs.os.dhhs.gov/  phs/ phs.html 
http:  / / www.os.dhhs.gov 

Medscape  is  a Web  site  that  is  designed  to  help 
physicians,  health  care  professionals,  and  con- 


J La  State  Med  Soc  VOL  152  September  2000  439 


sumers  stay  informed  about  recent  health  care 
developments  in  clinical  medicine  and  in  health 
care  policy. 

http:/  / www.medscape.com 

Physicians  On  Line  (POL)  offers  online  access 
to  comprehensive  medical  resources,  including 
medical  news  and  publications,  discussion 
groups,  a free  e-mail  service,  and  a free  Web  site 
for  your  office.  Physicians  can  log  in  or  register 
for  POL  without  installing  software, 
http:  / / www.pol.com 
http:  / / www.pol.net 

Reuters  Health  Information,  Inc.  (RHI)  is  a sub- 
scription service,  which  produces  one  of  the  pre- 
miere health  and  medical  global  daily  news  ser- 
vices for  keeping  both  professionals  and  con- 
sumers abreast  of  breaking  news  stories  in  health 
care. 

http:  / / www.reutershealth.com 

An  Index  of  the  Pediatric  Internet,  PEDINFO,  is 
dedicated  to  the  dissemination  of  online  infor- 
mation for  pediatricians  and  others  interested 
in  child  health.  It  is  divided  into  two  major  sub- 
divisions. 

http:  / / www.pedinfo.org 
http:  / / www.pedinfo.org/ 

SubSpec_Medl  .html 
http:  / / www.pedinfo.org/ 
SubSpec_Surg.html 

New  Orleans  Citywide  Rounds  is  produced 
weekly  and  is  attended  by  all  infectious  disease 
specialists  in  the  region,  as  well  as  fellows,  resi- 
dents, and  students  rotating  in  the  four  teach- 
ing programs,  including  LSU  Medical  Center, 
Tulane  University  School  of  Medicine,  Ochsner 
Foundation  Hospital,  and  the  LSU  / Tulane  Com- 
bined Pediatric  Infectious  Disease  Program, 
http:/  / www.medscape.com/SCP/ 

IIM/  public/  columns/ 
index-CitywideRounds.html 

The  Institute  of  Medicine  site  provides  objective, 
timely,  authoritative  information  and  advice  con- 


cerning health  and  science  policy  to  government, 
the  corporate  sector,  the  professions,  and  the 
public. 

http:  / / www.iom.edu 

The  Healtheon/ WebMD  site  uses  the  Internet  to 
facilitate  a new  system  for  the  delivery  of  health 
care,  resulting  in  a single,  secure  environment 
for  all  communications  and  transactions.  It  hopes 
to  enable  a more  efficient  and  cost  effective 
health  care  system.  It  plans  to  connect  all  par- 
ties in  health  care  - from  patients  to  physicians 
to  hospitals  to  insurers  to  employers  and  all  other 
health  care  organizations  in  order  to  foster  com- 
munication and  interaction  - and  ultimately  im- 
prove the  overall  quality  of  health.  It  collects 
articles  on  a wide  variety  of  medical  subjects  as 
well  as  supplying  governmental  regulations  and 
methods  for  dealing  with  them, 
http:/  / www.webmd.com 

WebEBM  is  a clinical  decision  support  company 
that  provides  Web-enabled,  evidence-based 
guidelines  for  physicians  and  their  patients.  It 
offers  online  tools  that  enable  physicians  to  track 
and  evaluate  patient  outcome  indicators,  com- 
pliance, and  satisfaction.  WebEBM  guidelines  are 
assembled  under  a unique  plan  drawing  on  the 
combined  expertise  of  five  of  the  leading  aca- 
demic medical  centers  in  the  United  States.  It 
aims  to  help  doctors  keep  up  with  the  best  treat- 
ments for  hundreds  of  common  diseases  and 
medical  conditions. 

http:  / / www.webebm.com 

The  Web  site  ACHOO  acts  as  a jump  point  and 
information  resource  for  the  medical  community 
and  other  Internet  users  interested  in  health  care 
information.  They  have  chosen  to  adopt  a wider 
and  more  comprehensive  interpretation  of 
"health",  which  includes  not  only  clinical  medi- 
cine, but  also  alternative  medicine  and  the  busi- 
ness aspects  of  medicine, 
http:  / / www.achoo.com 

More  medical  search  engines: 

Citeline.com: 

http:/  / www.citeline.com 


440  J La  State  Med  Soc  VOL  152  September  2000 


MedWebPlus: 

http:  / / www.medwebplus.com 
Medical  Matrix: 

http:  / / www.medmatrix.org 
Medical  World  Search: 

http:  / / www.mwsearch.com 
University  of  Texas  SUMSearch: 

http:  / / www.sumsearch.uthscsa.edu 
CliniWeb  International: 

http:  / / www.ohsu.edu  / cliniweb 
Clinical  cancer  trial  information  can  be  viewed 
at  both  the  University  of  Pennsylvania  Cancer 
site  and  at  OncoLink. 

http:  / / www.nlm.nih.gov / medlineplus  / 
cancers.html 

http:/  / www.oncolink.upenn.edu 

MEDICAL  TEXTBOOK  WEB  SITES 

The  content  of  the  Web  site,  eMedicine,  is  de- 
signed primarily  for  use  by  qualified  physicians 
and  other  medical  professionals.  It  provides  sales 
of  medical  textbooks  as  well  as  a new  concept 
for  viewing  online  some  medical  textbooks  that 
are  "in  process"  of  development.  Those  under 
development  can  be  improved  or  updated  24 
hours  a day,  365  days  a year.  The  site  allows  un- 
limited access  to  thousands  of  x-rays,  color  il- 
lustrations, and  pictures.  It  permits  the  reader 
to  instantly  send  comments  and  questions  as 
well  as  providing  new  images  for  the  topic  au- 
thor. It  additionally  allows  online  viewing  of 
author's  topic  lectures  and  procedures  both  for 
interested  medical  practitioners  and  the  general 
public. 

http:  / / www.emedicine.com 

LOCATORplus  is  the  National  Library  of 
Medicine's  catalog  of  books,  journals,  audio- 
visuals, and  access  points  to  other  medical 
research  tools. 

http:  / / www.nlm.nih.gov / locatorplus / 
locatorplus.html 

CREDIBILITY  OF  CONSUMER  HEALTH  SITES 

The  Internet  has  become  one  of  the  most  widely 
used  communication  medium.  Gina  Kolata, 


medical  writer  for  the  New  York  Times,  recently 
estimated  that  more  than  100,000  medical  Web 
sites  now  exist  on  the  Internet.2  With  the  avail- 
ability of  Web  server  software,  anyone  can  set 
up  a Web  site  and  publish  any  kind  of  data, 
which  is  then  accessible  to  all.  The  problem  no 
longer  is  finding  information  but  assessing  the 
credibility  of  the  publisher  as  well  as  the  rel- 
evance and  accuracy  of  a document  retrieved 
from  the  Net.  In  many  cases,  a given  Web  site 
provides  no  appropriate  documentation  regard- 
ing the  scientific  design  of  a medical  study,  nor 
are  studies  made  available  that  support  given 
claims.  Many  of  us  have  had  the  experience  of  a 
patient  bringing  an  Internet  printout  to  the  of- 
fice for  our  evaluation.  As  physicians,  we  need 
to  be  able  to  critically  evaluate  information  on 
the  Web. 

http:  / / www.nytimes.com 

Self-regulation  is  the  current  status  of  Web  data 
oversight.  There  is  no  common  legal  framework 
for  the  provision  of  health  care  information  on 
the  Internet  and  other  online  services,  but  health 
information  providers  can  apply  for  the  Health 
on  the  Net  Foundation's  Code  of  Conduct 
(HONcode)  "seal  of  approval".  This  seal  works 
similarly  to  a physician's  voluntary  credentialing 
by  specialty  boards  or  by  a hospital's  voluntary 
certification  by  the  Joint  Commission  for  the 
Accreditation  of  Hospital  Organizations  (JCAHO). 
It  helps  to  assure  consumers  that  certified  sites 
adhere  to  basic  good  standards  for  the  presenta- 
tion of  health  care  advice  and  information. 

The  Health  On  the  Net  Foundation's  Code 
of  Conduct  helps  standardize  the  reliability  of 
medical  and  health  information  available  on  the 
World-Wide  Web.  The  HON  code  defines  a set 
of  rules  to: 

• hold  Web  site  developers  to  basic  ethical 
standards  in  the  presentation  of  information; 
and 

• help  ensure  that  readers  always  know  the 
source  and  the  purpose  of  the  data  they  are 
reading. 

http:  / / www.hon.ch/honcode/ 
conduct.html 


J La  State  Med  Soc  VOL  152  September  2000  441 


Demonstrating  the  importance  of  this  issue,  on 
May  7, 2000,  a group  of  health-oriented  Web  sites 
put  forth  the  first  industry-led  ethical  standards 
and  privacy  protections  for  users  of  their  popu- 
lar sites.  The  principles  laid  out  by  the  Health 
Internet  Ethics  group  have  been  endorsed  by  20 
leading  online  health  companies,  including 
PlanetRx.com,  Healtheon/  WebMD,  Medscape 
Inc,  DrKoop.com,  and  the  internet  service  pro- 
vider America  Online,  which  also  agreed  to  ap- 
ply the  guidelines  to  its  online  health-related 
sites.  There  remains,  however,  the  lack  of  en- 
forcement mechanism  or  consumer  recourse  if 
privacy  rights  are  violated, 
http:  / / www.hiethics.org 
http:  / / www.planetrx.com 
http:  / / www.webmd.com 
http:  / / www.medscape.com 
http:  / / www.drkoop.com 
http:  / / www.aol.com 

CONSUMER  HEALTH  INFORMATION 
WEB  SITES 

MEDLINE  plus  has  been  designed  for  use  by 
both  health  professionals  and  consumers  for  ac- 
curate, current,  medical  information.  This  ser- 
vice provides  access  to  extensive  information 
about  specific  diseases  and  conditions  and  also 
has  links  to  consumer  health  information  from 
the  National  Institutes  of  Health,  dictionaries, 
lists  of  hospitals  and  physicians,  health  informa- 
tion in  Spanish  and  other  languages,  and  clini- 
cal trials. 

http:  / / www.nlm.nih.gov  / medlineplus 
http:/  / www.nih.gov 

A Web  site  to  display  the  product  of  clinical  tri- 
als has  been  developed  by  the  US  National  In- 
stitutes of  Health,  through  its  National  Library 
of  Medicine,  to  provide  patients,  family  mem- 
bers, and  members  of  the  public  with  current 
information  about  clinical  research  studies, 
http:  / / clinicaltrials.gov/ct/ gui 
http:/  / www.nlm.nih.gov 

Healthfinder  is  a free  gateway  to  reliable  con- 
sumer health  and  human  services  information 


that  was  developed  by  the  US  Department  of 
Health  and  Human  Services  and  coordinated  by 
the  Office  of  Disease  Prevention  and  Health  Pro- 
motion (ODPHP).  It  can  lead  the  viewer  to  se- 
lected online  publications,  clearinghouses,  da- 
tabases, Web  sites,  and  support  and  self-help 
groups  as  well  as  to  the  government  agencies 
and  not-for-profit  organizations  that  produce 
reliable  information  for  the  public. 

http:  / / www.healthfinder.gov 

Reuters  Health  eLine  is  a FREE  consumer-ori- 
ented medical  news  service.  Their  daily  news 
feed  of  15-20  stories  per  day  provides  consum- 
ers with  in-depth  medical  information  that  is 
easy  to  understand. 

http:  / / www.reutershealth.com 

HealthGate  is  an  electronic  source  of  objective 
and  credible  health  and  medical  information  for 
health  care  professionals,  their  patients,  and  con- 
sumers. 

http:  / / www.healthgate.com 

CBS  Health  Watch  offers  an  array  of  high  qual- 
ity information  and  interactive  tools  to  help  con- 
sumers and  their  families  manage  their  daily 
personal  health.  It  utilizes  Medscape,  Inc.,  which 
is  a site  primarily  for  health  care  professionals. 
It  has  earned  a strong  following  among  consum- 
ers who  seek  cutting-edge,  authoritative  content 
that  they  cannot  find  on  traditional  consumer 
health  sites. 

http:  / / www.cbshealthwatch.medscape.com 

http:  / / www.medscape.com 

The  InteliHealth  expert  editors  "consumerize" 
health  information  to  make  it  accessible  to  the 
widest  possible  audience.  This  Web  site  has  links 
to  huge  volumes  of  very  well-done  articles  and 
data  which  discuss  medical  topics  of  pro- 
fessional quality  but  in  layman  terms. 

http:/  / www.intelihealth.com 

The  Mayo  Clinic  On-Line  site  is  directed  by  a 
team  of  Mayo  physicians,  scientists,  writers,  and 
educators,  who  update  the  Mayo  Clinic  Health 


442  J La  State  Med  Soc  VOL  152  September  2000 


Oasis  Web  site  each  weekday  to  provide  health 
education  to  their  patients  and  the  general 
public. 

http:/  / www.mayohealth.org 

Doctors  Who's  Who  empowers  doctors  and  con- 
sumers with  the  necessary  resources  to  make 
careful  evaluations  regarding  their  medical 
needs  and  to  provide  comprehensive  health  care 
information.  It  provides  a search  engine  for  find- 
ing a physician  by  specialty,  geographic  location, 
accepted  insurance  plans,  professional  qualifi- 
cations, personal  views  of  their  practice,  office 
hours,  and  a map  to  their  office.  It  contains  in- 
formation on  medical  news,  health  tips,  and  dis- 
ease entities. 

http:  / / www.doctorswhoswho.com 

On  Health  provides  information  for  consumers 
about  medical  disorders  but  also  emphasizes 
wellness  and  fitness  issues.  The  scientific  infor- 
mation is  presented  in  layman's  language.  It  in- 
cludes a comprehensive  database  of  drugs  and 
conditions,  a searchable  medical  dictionary,  in- 
dexes of  herbs  and  allergy  information,  guides 
to  supplements  and  alternative  practices,  reports 
on  timely  topics,  a useful  interactive  tool,  and  a 
personalized  e-mail  service  that  will  send  articles 
related  to  your  specific  interests. 

http:  / / www.onhealth.com /home/ 
index.asp 

ThriveOnLine  provides  innovative  solutions  and 
credible  information  on  staying  healthy,  manag- 
ing illness,  and  living  well.  It  features  program- 
ming in  six  major  areas  covering  the  breadth  of 
a healthy  life:  medical,  fitness,  nutrition,  sexual- 
ity, weight,  and  serenity  (a  stress  management 
and  wellness  area). 

http:/  / www.thriveonline.com 

The  Galen  Institute  is  a not-for-profit  public 
policy  organization  devoted  to  research  and  edu- 
cation on  health  and  tax  policy,  which  brings  a 
unique  approach  to  public  policy  research.  It 
serves  as  a broker  of  the  ideas  of  the  top  experts 
in  the  market-based  policy  community.  Their 


goal  is  to  expand  public  education  about  free- 
market  ideas  to  invigorate  a consumer-driven 
market  for  health  services  and  increase  access 
to  affordable,  privately-owned  health  insurance. 

http:  / / www. galen.org 

The  Integrated  Healthcare  Association  (IHA)  is 
a California  leadership  group  of  health  plans, 
physician  groups,  and  health  systems  plus  at- 
large  academic,  purchaser,  pharmaceutical 
industry,  and  consumer  representatives 
involved  in  policy  development  and  special 
projects  around  integrated  health  care  and 
managed  care.  Its  mission  is  to  promote  the 
continuing  evolution  of  integrated  health  care, 
supported  by  financial  mechanisms  that  align 
incentives  of  purchasers,  payors,  and  providers 
as  the  best  means  to  achieve  positive  outcomes 
for  the  patient  and  the  general  public.  Their  Web 
site  contains  the  principles  of  managed  health 
care,  which  the  IHA  believes  managed  care 
organizations  should  uphold,  with  a Managed 
Health  Care  glossary  of  terms,  issue  papers  on 
access,  medical  decision  making,  quality  of  care 
and  consumer  satisfaction,  and  Medicare. 

http:/  / www.iha.org 

The  National  Coalition  on  Health  Care  is  the 
nation's  most  broadly  representative,  non-par- 
tisan, non-profit  alliance,  which  is  working  to 
improve  America's  health  and  health  care  sys- 
tem. It  produces  excellent  studies  and  reports 
with  recommendations.  Its  nearly  100  members 
include  large  and  small  businesses,  labor  unions, 
consumer  groups,  and  health  professional  and 
religious  organizations. 

http:  / / www.nchc.org 

CONTINUING  MEDICAL  EDUCATION 
WEB  SITES 

There  are  a number  of  interactive,  convenient 
examples  of  online  CME  sites,  which  for  some 
physicians  may  be  useful  and  merit  trying.  The 
MedCases  site  provides  a distinctive  problem- 
based  learning  method,  which  utilizes  a 
comprehensive  set  of  realistic  cases  where 


J La  State  Med  Soc  VOL  152  September  2000  443 


"simulated  patients"  present  specific  medical 
complaints.  Acting  as  the  treating  physician,  you 
solve  cases  using  information  requested  from  the 
patient's  medical  file  - determining  a differential 
diagnosis,  conducting  laboratory  tests, 
completing  a final  diagnosis,  and  prescribing  an 
appropriate  course  of  treatment.  At  each  step 
along  the  way,  background  information  and 
evidence-based  rationale  is  available  from  their 
panel  of  experts.  The  dynamic  interactivity  of 
the  simulated  cases  allows  learners  to  customize 
each  instructional  session  and  proceed  at  their 
own  pace. 

http:  / / www.medcases.com 

The  Virtual  Lecture  Hall  Web  site  is  presented 
by  Medical  Directions,  Inc,  a leading  medical 
education  company,  and  is  devoted  to  improv- 
ing the  state  of  online  continuing  medical  edu- 
cation (CME)  programs  for  health  professionals. 

http:  / / www.vlh.com 

PROVIDER  EVALUATIONS 
FOR  CONSUMERS 

Physician  board  certification  can  be  found  at  the 
interactive  Web  site  version  of  the  American 
Board  of  Medical  Specialties  (ABMS).  This  site 
allows  the  public  to  verify  the  board  certification 
status,  location  by  city  and  state,  and  specialty 
of  any  physician  certified  by  one  or  more  of  the 
24  Member  Boards  of  the  ABMS. 

http:  / / www.certifieddoctor.org 

The  Health  Care  Report  Cards  site  provides 
ratings  on  hospitals,  physicians,  nursing  homes, 
health  plans,  and  other  providers. 

http:  / / www.healthgrades.com 

Physician  report  cards,  which  detail  physician 
profiles,  maps  and  driving  directions,  and  links 
to  physician  Web  sites  can  be  found  as  an 
extension  of  the  URL  immediately  above. 

The  National  Committee  for  Quality  Assurance 
(NCQA)  provides  "Report  Cards"  for  managed 
care  plans  by  offering  comprehensive 


information  about  the  clinical  performance, 
member  satisfaction,  access  to  care,  and  overall 
quality  of  over  half  of  the  650  managed  care 
plans  in  the  United  States.  Health  plans  that  meet 
the  standards  receive  NCQA  Accreditation, 
which  is  nationally  recognized  as  a "seal  of 
approval". 

http:  / / www.ncqa.org 

The  Foundation  for  Accountability  (FACCT)  is 
a not-for-profit  organization,  which  is  dedicated 
to  helping  Americans  make  better  health  care 
decisions.  FACCT's  board  of  trustees  is 
composed  of  consumer  organizations, 
purchasers  of  health  care  services,  and  insurance 
providers  representing  80  million  Americans. 
FACCT  creates  tools  that  help  people 
understand  and  use  quality  information, 
develops  consumer-focused  quality  measures, 
supports  public  education  about  health  care 
quality,  supports  efforts  to  gather  and  provide 
quality  information,  and  encourages  health 
policy  to  empower  and  inform  consumers. 
FACCT  is  developing  and  testing  consumer- 
focused  educational  materials  designed  to  help 
people  understand  key  facts  about  health  care 
quality,  demand  quality  information,  and  begin 
to  use  it  when  making  decisions. 

http:  / / www.facct.org 

The  National  Research  Corporation  (NRC) 
DoctorGuide  is  an  initiative  to  provide  the  health 
care  industry  with  the  information  needed  to 
pursue  continual  quality  improvement  in 
clinical  care  and  practices,  as  well  as  to  empower 
consumers  and  assist  them  in  their  selection  of 
a physician  who  meets  their  needs.  It  ultimately 
plans  to  provide  scientifically  sound  data  to  both 
consumers  and  the  industry  by  measuring  every 
primary  care  physician  in  the  nation.  Through 
collaborative  efforts,  NRC  will  query  a 
substantial  number  of  patients,  who  have  visited 
all  primary  care  physicians  in  markets 
throughout  the  United  States.  Selected  relevant 
data  will  be  made  available  to  physicians, 
consumers,  employers,  health  plans,  medical 
groups,  policy  makers,  and  all  parties  interested 


444  J La  State  Med  Soc  VOL  152  September  2000 


in  improving  the  quality  and  effectiveness  of  the 
health  care  system  in  the  nation. 

http:  / / www.doctorguide.com 

OFFICE  PATIENT  MEDICAL  RECORDS 
ONLINE 

Logician  Internet  is  a Web-Enabled  Documen- 
tation Tool  for  Clinicians  to  document  patients' 
visits.  Free  "initially"  until  you've  created  your 
first  100  charts.  Logician  Internet  then  charges  a 
monthly  rate  of  $99.  This  system  allows  physi- 
cians to  input  patient  information  into  the  medi- 
cal record.  It  screens  the  medical  record  for 
proper  coding,  allows  patients  to  input  pertinent 
medical  information  into  the  system,  allows  pa- 
tients to  obtain  laboratory  results  and  send  e- 
mail  requests  for  prescription  refills,  allows 
Internet-based  messaging  tools  to  order  prescrip- 
tions, and  enables  physicians  to  order  and  ob- 
tain laboratory  results.  With  it  you  can  create 
HCFA-compliant  documentation  of  your  patient 
encounters,  possibly  reduce  transcription  costs, 
avoid  defensive  down-coding  with  automated 
E&M  coding,  create  more  legible  documentation, 
and  securely  access  key  patient  information  from 
any  Web  browser. 

http:  / / www.medicalogic.com/ products/ 
logician_internet 

MedicaLogic/Medscape  is  a new  company 
formed  from  the  merger  of  three  other  compa- 
nies. Medscape,  the  premier  source  of  authori- 
tative health,  news,-  and  medical  information  on 
the  Internet,  merged  with  MedicaLogic,  the 
nation's  leading  provider  of  online  health 
records,  and  Total  eMed,  the  first  provider  of 
Web-based  transcription  services  designed  for 
ambulatory  care  physicians.  The  expectation  is 
that  this  combination  will  enable  the  65%  of  US 
physicians  using  transcription  services  to  con- 
nect with  MedicaLogic' s clinical  tools  to  create 
online  health  records.  Medscape  editor-in-chief, 
George  D.  Lundberg,  MD,  former  editor  of 
JAMA,  will  continue  his  role  in  the  new  company. 

http:  / / www.medscape.com 


DATAMED  Forms  & Software,  Inc.  developed 
the  Dr  Notes  Program  to  save  physicians'  time 
and  money  by  eliminating  dictation  and  tran- 
scription. It  enables  documentation  according  to 
HCFA's  "Guidelines  for  Evaluation  and  Man- 
agement Levels".  The  Program  produces:  pre- 
scriptions, narrative  reports,  orders,  patient  in- 
structions, diets,  and  "automatically  coded" 
Super  bills. 

http://www.drnotes.com 

For  an  excellent  article  on  "The  Business  Case 
for  an  Electronic  Medical  Record  (EMR)  System" 
visit  the  ENTNet  Web  site.3 

http:  / / www.entnet.org  / Bulletin / 
technology.html 

To  learn  even  more,  explore  these  EMR  sites: 

Physician  Micro  Systems: 
http:/  / www.pmsi.com 
GVT  Medical  Records: 

http:  / / www.gvtgems.com 
ELIXIS: 

http:  / / www.elixis.com 
MedicaLogic: 

http:  / / www.medicalogic.com 
Medical  Manager  Corporation: 

http:  / / www.medicalmanager.com 
Medscape's  Free  Physician  Web  Sites: 
http:  / / www.medscape.com 

FEDERAL  GOVERNMENT 
SITES  OF  INTEREST 

Louisiana  Congressmen: 

http:  / / www.visi.com/juan/ congress/ cgi- 
bin  / buildpage . cgi?  state=la 
How  to  contact  members  of  Congress: 
http:/  /congress.nw.dc.us/ama/ 
elecmail.html 

http:  / / www.visi.com/juan/ congress 
http:  / / legislators.com/latimes/ 
congdir.html 

http:  / / congress.nw.dc.us/rollcall 
Official  Federal  Government  Web  sites: 
http://lcweb.loc.gov/global/  executive/ 
fed.html 


J La  State  Med  Soc  VOL  152  September  2000  445 


Library  of  Congress  home  page: 
http:/  / www.loc.gov 
The  Federal  Register: 

http:  / / www.access.gpo.gov/  nara/#fr 
The  Thomas  site,  which  provides  Legislative  in- 
formation from  the  Library  of  Congress,  helps 
in  searching  for  Bills  passed  or  under  consider- 
ation by  Congress. 

http:  / / thomas.loc.gov /home/ 
thomas2.html 

The  US  Department  of  Health  and  Human  Ser- 
vices (DHHS)  provides  actual  Congressional  tes- 
timonies. 

http:  / / www.hhs.gov/  progorg/  oas/ 
testimony.html 

The  Health  Care  Finance  Administration 
(HCFA)  includes  the  Medicare,  Medicaid,  and 
State  Children's  Health  Insurance  Program 
(SCHIP)  agencies. 

http:  / / www.hcfa.gov 

US  Department  of  Health  and  Human  Services: 
http:  / / www.os.dhhs.gov 
Centers  for  Disease  Control  and  Prevention 
(CDC): 

http:/  / www.cdc.gov 
Travelers'  Health  Page: 

http:/  / www.cdc.gov /travel 
Morbidity  and  Mortality  Weekly  Report: 
http:  / / www2.cdc.gov/mmwr 
Center  for  Drug  Evaluation  and  Research: 
http:  / / www.fda.gov/  cder 
Emerging  Infectious  Diseases: 

http:  / / www.cdc.gov/  ncidod/eid 
National  Center  for  Policy  Analysis  on  Health 
Issues: 

http:  / / www.ncpa.org  / pi  / health  / 
hedexl.html 

LOUISIANA  STATE  GOVERNMENT  SITES 

Louisiana  State  Senate: 

http:/  / senate.legis.state.la.us 
Louisiana  House  of  Representatives: 
http:  / /house.legis.state.la.us 
Louisiana  Medicare  Part  B: 

http:/  / www.lamedicare.com 
Library  of  Congress  list  of  Louisiana  State  & 


Local  Government  sites: 

http:  / / lcweb.loc.gov/ global/ state /la- 
gov.html 

Library  of  Congress  list  of  all  state  government 
Web  sites: 

http:  / / lcweb.loc.gov/ global / state/ 
stategov.html 

Louisiana  State  and  Local  Government  sites  by 
Piper  Resources: 

http:  / / www.piperinfo.com/ state/ slla.html 
The  Office  of  the  Louisiana  Register,  which  is 
the  state's  official  medium  for  making 
administrative  law  documents  public.  In 
addition,  the  office  compiles  the  rules  by  subject 
area  into  the  Louisiana  Administrative  Code. 

http:  / / www.doa.state.la.us/  osr/  osr.htm 
Louisiana  Department  of  Insurance: 
http:  / / www.ldi.ldi.state.la.us 

POLITICAL  “GRASSROOTS”  SITES 

Almost  daily  there  are  political  issues  that  have 
a major  impact  on  the  practice  of  medicine  at 
the  federal  or  state  level.  We  ignore  them  at  our 
peril.  It  is  critical  for  physicians  to  become 
knowledgeable  about  the  issues,  which  requires 
constant  perusing  of  routine  news  sources  or, 
more  effectively  and  efficiently,  those  provided 
by  our  medical  organizations  for  us.  The  AMA 
and  our  Specialty  societies  do  an  excellent  job 
on  a national  level,  while  our  state  and  parish 
societies  keep  us  informed  on  a more  local  level. 
Once  aware  of  issues,  it  then  becomes  impor- 
tant to  convey  our  opinions  to  the  appropriate 
political  representative,  so  as  to  have  the  most 
effect.  Today,  this  is  most  quickly  and  easily  done 
over  the  Internet,  and  all  of  our  societies  are  uti- 
lizing this  incredible  tool.  We  must  take  advan- 
tage of  this  "membership  benefit"  effort  on  our 
behalf. 

The  AMA  Advocacy  Resource  Center  (ARC) 
has  a password-protected  Members-Only  Web 
site,  which  contains  comprehensive  materials 
and  information  on  each  political  or  socio- 
economic issue. 

http:  / / www.ama-assn.org /ARC 


446  J La  State  Med  Soc  VOL  152  September  2000 


Our  own  Louisiana  State  Medical  Society 
(LSMS)  Web  site  has  continually  updated 
subcategories  including:  "Current  Affairs"  with 
information  on  Medicare,  Medicaid,  Managed 
Care,  and  federal  and  local  on-going  issues; 
"Clippings"  with  recent  medical  health  care 
system  articles;  LSMS  or  AMA  press  releases  or 
Bulletins;  special  "ALERTS";  "State  Legislative" 
activities  with  the  "LSMS  Grassroots  Action 
Center",  which  contains  help  for  contacting  your 
state  or  federal  legislators  as  well  as  providing 
sample  letters  on  the  particular  topic;  and  the 
"Grassroots  E-mail  Action  Team"  for  a "quick 
response"  to  breaking  new  issues, 
http:  / / www.lsms.org 

Most  national  and  state  specialty  societies,  and 
some  parish  societies,  have  their  own  Web  site 
versions  of  these  "Grassroots"  response  mecha- 
nisms for  dealing  with  individualized  issues. 

CONSUMER  ORGANIZATIONS 

Families  USA  is  a national,  nonprofit,  non- 
partisan organization  dedicated  to  the 
achievement  of  high-quality,  affordable  health 
and  long-term  care  for  all  Americans.  Acting  as 
a "watchdog"  over  government  actions  affecting 
health  care,  they  alert  consumers  to  changes  and 
help  them  have  a say  in  the  development  of 
policy  by  managing  a grassroots  advocates' 
network  of  organizations  and  individuals  to 
work  for  the  consumer  perspective  in  the 
national  and  state  health  policy  debates.  They 
produce  health  policy  reports  describing  the 
problems  facing  health  care  consumers  and 
outlining  steps  to  solve  them, 
http:  / / www.familiesusa.org 

The  Kaiser  Family  Foundation  provides 
excellent  information  on  current  medical  topics. 
It  plans  to  broadcast  major  health  policy  events 
on  the  Web  as  a service  to  the  health  policy 
community,  the  news  media,  and  the  general 
public.  Their  new  HealthCast  site  offers  a free 
service  to  provide  regular  coverage  of  important 
health  events  in  Washington  and  across  the 


country,  including  congressional  hearings, 
meetings,  and  press  conferences, 
http:  / / www.kff.org 
http:/  / www.healthcast.org 

The  National  Association  of  Insurance 
Commissioners  includes  insurance  regulators 
from  all  50  states,  the  District  of  Columbia,  and 
the  four  US  Territories.  Their  site  provides  a 
forum  for  the  development  of  uniform  policy 
when  uniformity  is  appropriate.  It  provides 
news,  publications,  policy  statements,  model 
state  laws  and  regulations,  and  other  services, 
http:/  / www.naic.org 

Advice  for  consumers  on  buying  medical 
products  is  available  from  the  government 
online. 

http:  / / www.fda.gov/  oc/  buy  online 

The  American  Association  of  Retired  Persons 
(AARP)  develops  and  works  nationally  to 
achieve  its  policy  agendas.  It  is  a private,  non- 
profit membership  organization,  which  makes 
products  and  services  available  to  its  members 
through  service  providers.  The  Association  it- 
self does  not  sell  services,  but  it  licenses  the  use 
of  its  name  for  the  selected  services  of  chosen 
providers.  The  Association  receives  an  admin- 
istrative allowance  or  a royalty  from  the  provid- 
ers. The  income  realized  from  these  services  is 
used  for  the  general  purposes  of  the  Association 
and  its  members. 

http:  / / www.aarp.org 

Modern  Maturity  is  the  AARP's  magazine, 
http:  / / www.aarp.org/  mmaturity 

The  Gray  Panthers  is  an  activist  organization 
working  for  social  and  economic  issues  includ- 
ing universal  health  care,  jobs  with  a living  wage 
and  the  right  to  organize,  preservation  of  Social 
Security,  affordable  housing,  access  to  quality 
education,  economic  justice,  environment,  peace, 
and  challenging  ageism,  sexism,  and  racism, 
http:/  / www.graypanthers.org 


J La  State  Med  Soc  VOL  152  September  2000  447 


SOCIO-ECONOMIC  SITES 

Modern  Physician  magazine  contains  business 
information  for  doctors. 

http:  / / www.modernphysician.com 

Modern  Healthcare  is  a weekly  health  care 
business  news  source. 

http:  / / www.modernhealthcare.com 

PDR.net  is  a medical  and  health  care  Web  site 
created  by  Medical  Economics  Company,  Inc., 
publisher  of  health  care  magazines  and  directo- 
ries including  the  Physicians'  Desk  Reference 
(PDR).  It  targets  physicians,  nurses,  physician 
assistants,  and  consumers  with  medical  and 
socio-economic  information, 
http:  / / www.pdr.net 

Weiss  Ratings,  Inc.  provides  regularly  updated 
ratings  on  the  financial  strength  of  more  than 
16,000  institutions  - including  nearly  all  of  the 
health  insurers,  HMOs,  and  Blue  Cross  \ Blue 
Shield.  A health  insurance  policy  or  contract  is 
only  as  secure  as  the  insurance  company  issuing 
it.  Therefore,  it  is  important  to  periodically 
monitor  the  financial  condition  of  each  company 
with  which  you  have  a relationship, 
http:  / / www.weissratings.com 

The  American  Association  of  Health  Plans  is  the 
national  trade  association  representing  more 
than  1,000  health  maintenance  organizations, 
preferred  provider  organizations,  point-of-ser- 
vice  plans,  and  other  similar  health  plans  that 
care  for  more  than  140  million  Americans, 
http:  / / www.aahp.org 

The  Medical  Group  Management  Association  is 
the  leading  organization  representing  medical 
group  practices  nationwide.  More  than  7,100 
health  care  organizations  and  nearly  20,000 
individuals  are  MGMA  members,  representing 
more  than  185,000  physicians.  Their  core 
purpose  is  to  improve  the  effectiveness  of 
medical  group  practices  and  the  knowledge  and 
skills  of  the  individuals  who  manage  / lead  them, 
http:/  / www.mgma.com 


The  American  Hospital  Association  (AHA)  is  the 
national  organization  that  represents  and  serves 
all  types  of  hospitals,  health  care  networks,  and 
their  patients  and  communities.  Close  to  5,000 
institutional,  600  associate,  and  40,000  personal 
members  come  together  to  form  the  AHA. 
Through  its  representation  and  advocacy  activi- 
ties, AHA  ensures  that  members'  perspectives 
and  needs  are  heard  and  addressed  in  national 
health  policy  development,  legislative  and  regu- 
latory debates,  and  judicial  matters, 
http:  / / www.aha.org 

American  Medical  News  (AMNews)  is  a weekly 
newspaper  for  physicians,  published  by  the 
American  Medical  Association.  With  a 
circulation  of  about  350,000,  it  is  the  nation's 
best-read  newspaper  on  professional,  social,  and 
economic  and  policy  issues  in  medicine. 
AMNews  is  a current-awareness  news  source  that 
follows  standard  journalistic  practices  for 
fairness  and  accuracy,  under  the  direction  of  the 
publication's  section  editors  and  editor-in-chief. 
Topic  editors  and  the  copy  desk  rigorously 
scrutinize  both  topic  and  content  for  accuracy 
and  consistency. 

http:/  / www.ama-assn.org /public/ 
journals/  amnews 

ONLINE  NEWSPAPERS  FOR  FINDING 
MEDICALLY-ORIENTED  ARTICLES 

All  Louisiana  Newspaper  Links: 

http:  / / www.microzoo.com/lanews.html 
Times  Picayune: 

http:  / / www.nola.com / t-p 
CityBusiness  of  New  Orleans: 

http:  / / www.neworleans.com/  citybusiness 
The  Baton  Rouge  Advocate: 

http:  / / www.theadvocate.com 
AMNews: 

http:/  / www.ama-assn.org /public/ 
journals/  amnews 
USAToday: 

http:  / / www.usatoday.com 
Medical  Economics  Magazine: 
http:  / / www.pdr.net/memag 


448  J La  State  Med  Soc  VOL  152  September  2000 


Wall  Street  Journal  On  Line  (by  subscription): 
http: / / interactive.wsj.com 
The  Washington  Times: 

http:/  / www.washtimes.com 
Boston  Globe: 

http:/  / www.boston.com 
New  York  Times  on  the  Web: 
http:/  / www.nytimes.com 
Physician  News  Digest: 

http:  / / www.southeastern-pa@ 
physiciansnews.com 
Chicago  Tribune: 

http:/  / www.chicago.tribune.com 
Excite's  News  Tracker  Clipping  Service: 
http:/  / nt.excite.com 

Medical  Industry  Today  will  send  articles  daily 
by  e-mail. 

http:  / / www.medicaldata.com/  mit 
Houston  Chronicle: 

http:/  / www.chron.com 
Los  Angeles  Times: 

http:  / / www.latimes.com 
The  Drudge  Report  contains  a large  assortment 
of  current  news  stories,  some  inflammatory  or 
"sensational"  articles,  and  links  to  well-known 
authors'  recent  articles  and  to  many  magazines 
and  newspapers. 

http:  / / www.drudgereport.com 
The  Washington  Post: 

http:/  / www.washingtonpost.com 
Individual.com  is  the  world's  leading  provider 
of  free,  individually  customized  news, 
information,  and  services  over  the  Internet.  It 
enables  you  to  create  your  own  FREE 
individualized  Personal  News  Page  with  daily 
e-mail,  brief  summaries  of  articles  on  topics  you 
choose,  and  links  to  the  full  article, 
http:/  / www.individual.com 

ONLINE  MUTUAL  FUND  FAMILIES  AND 
BROKERAGE  HOUSES 

It  has  become  very  easy  for  physicians  to  man- 
age their  retirement  plans,  IRAs,  and  personal 
finance  data  over  the  Internet.  All  of  the  Broker- 
age houses,  Fund  Families,  Insurance  entities, 
and  Banks  now  offer  access  and  trading  via 


"password  protected"  Web  sites.  Utilizing  these 
Web  sites  places  financial  research  at  your  fin- 
gertips as  well  as  rapid  trading  of  assets  to  dif- 
ferent funds  and  purchasing  or  selling  stock.  This 
modality  is  cheaper  and  faster  than  trying  to 
reach  a broker  for  those  who  are  willing  to  use 
this  system.  You  can  set  up  a spreadsheet  of  as- 
sets on  EXCEL  or  another  spreadsheet  program 
and  regularly  update  values  of  your  account 
holdings  by  "surfing  the  net". 

Fidelity: 

http:/  / www300.fidelity.com 
Charles  Schwab: 

http:/  / www.schwab.com 
Vanguard: 

http:/  / www.vanguard.com 
USAA: 

https:  / / www.usaa.com 
Merrill  Lynch: 

http:  / / www.ml.com 
J.C.  Bradford  and  Co.: 

http:/  / www.jcbradford.com 
T.  Rowe  Price: 

http:/  / www.troweprice.com 
American  Century: 

http:  / / www.americancentury.com 

SHOPPING  FOR  MEDICAL  SUPPLIES 
ONLINE 

Presently,  Internet  firms  selling  medical  supplies 
can  claim  only  a small  fraction  of  the  nation's 
doctors  as  customers.  But  usage  is  expected  to 
soar  this  year.  When  MedicalBuyer.com  sur- 
veyed 300  of  its  doctor  customers  in  1999,  only 
one  in  five  had  Internet  access  at  the  office.  "By 
the  end  of  2000,  we  expect  half  to  have  Internet 
connections  at  work",  predicts  radiologist  Ed- 
ward S.  Rollins,  the  company's  CEO.  "By  the  end 
of  2001,  it  could  be  80  percent."  According  to 
the  AMA,  self-employed  family  practitioners 
and  general  practitioners  spent  a median  $12,000 
on  medical  supplies  in  1996;  general  internists 
spent  a median  $9,000,  while  the  median  expen- 
diture for  all  physicians  was  $6,000.  Some  sites 
claim  overall  savings  of  25%  to  30%.3 
http:/  / www.medicalbuyer.com 


J La  State  Med  Soc  VOL  152  September  2000  449 


Medical  Supplies  USA.com  carries  over  350,000 
brand  name  products  in  stock  including: 
Vaccines,  Pharmaceuticals,  Medical  Supplies, 
Medical  Equipment,  Medical  Instruments, 
Office  Supplies,  Office  Furniture,  Surgical  Suites, 
New  Office  Set-ups,  Printing  and  Brochures, 
Business  Forms,  Copiers  and  Document  Centers, 
Computers  and  Peripherals,  Telephone  Systems, 
Consulting  and  Services,  and  IPA/MSO/TPA/ 
PPMC  supplies. 

http:  / / www.medicalsuppliesusa.com 

Other  medical  supply  sites: 
http:/  / www.equipmd.com 
http:/  / www.everything4mds.com 
http:  / / www.mdchoice.com 
http:  / / www.medibuy.com 

E-MAIL 

E-mail  is  cheaper  and  faster  than  a letter,  less 
intrusive  than  a phone  call,  and  less  hassle  than 
a FAX.  Addressees  respond  when  convenient  or 
even  instantly,  if  "on  line"  and  available  at  the 
same  time.  In  order  to  get  connected  to  the 
Internet,  you  need  an  ISP  (Internet  Service  Pro- 
vider). When  you  sign  up  with  an  ISP  you  auto- 
matically get  at  least  one  e-mail  account.  It  may 
be  useful  to  have  a "personal"  e-mail  address 
and  a separate  "professional"  address  for  dif- 
ferent types  of  contacts  and  to  avoid  "spammers" 
(advertisers). 

While  e-mail  is  widely  used  by  Americans 
for  personal  and  business  use,  currently  only 
2,000  of  our  LSMS  members  have  e-mail  ad- 
dresses listed  on  our  Web  site.  It  is  such  an  easy, 
non-obtrusive  way  to  communicate  and  make 
patient  "handouts"  available,  that  surely  it  will 
soon  explode  for  our  profession,  too. 

Most  e-mail  programs  allow  "attachments", 
which  allow  you  to  send  and  receive  files  that 
you  attach  to  your  e-mail,  such  as  pictures,  ar- 
ticles, sounds,  video,  slide  presentations,  and 
other  programs.  You  must  be  careful,  however, 
because  they  can  also  contain  software  "viruses" 
that  can  damage  your  computer.  You  must  be 
careful  about  accepting  attachments  from  some- 
one you  don't  know. 


You  can  pay  for  more  elaborate  e-mail  pro- 
grams or  you  can  get  one  free.  There  are  advan- 
tages to  both  and  you  might  want  one  of  each. 
E-mail  programs  can  also  have  other  features 
such  as  address  books,  calendars,  instant  mes- 
saging, and  chat  rooms  for  communicating  with 
many  people  at  once. 

Here  are  some  good  FREE  e-mail  programs  to 
check  out: 

Eudora: 

http:  / / www.eudora.com 
JUNO: 

http:  / / dl.www.juno.com 
Healthcare  Mail: 

http:/  / www.healthcaremail.com 
Physicians  On  Line  (POL) 

http:/  / www.pol.net 
Outlook  2000  - comes  with  MS  Office 
Outlook  Express  - comes  with  Internet  Explorer 

CHAT  ROOMS  OR  FORUMS 

Most  of  the  commercial  ISPs  use  special  software 
to  allow  Internet  users  to  simultaneously  enter 
chat  areas,  or  "chat  rooms",  where  they  can  com- 
municate in  real  time.  These  may  involve  "gen- 
eral public"  interaction  or  the  establishment  of 
"private"  chat  rooms  for  specific  "instant"  com- 
munication. This  is  becoming  more  sophisticated 
with  the  use  of  audio  and  even  video  communi- 
cation. These  "educational"  forums  are  also  be- 
ing used  in  many  other  realms  including  finan- 
cial discussions  provided  by  brokerage  houses 
or  direct  marketing  of  new  drugs  to  the  public 
by  pharmaceutical  entities. 

The  AMA  and  other  medical  societies  are 
currently  using  written  "forums",  to  enable  in- 
terested members  to  read  other's  comments  and 
respond  to  specific  issues  over  a period  of  days, 
weeks,  or  months  on  topics  of  specific  socio-eco- 
nomic interest.  Specialty  societies  use  the  forum 
concept  for  physician  interaction  on  specific  dis- 
eases, and  public  "health"  Web  Sites  are  utiliz- 
ing them  for  clinical  discussions  between  phy- 
sicians and  the  lay  public. 


450  J La  State  Med  Soc  VOL  152  September  2000 


VIRUS  HELP 

While  these  new  Internet  functions  are  exciting, 
there  remain  potential  hazards.  The  "love  bug", 
"Melissa",  and  other  viruses  demonstrated  just 
how  vulnerable  this  system  can  be.  E-mail, 
which  is  so  widely  used  by  all  professions,  gov- 
ernmental agencies,  financial  and  insurance  en- 
tities, and  the  military,  remains  unsecured. 
Health  care  information,  in  particular,  must  be 
secure  in  its  transfer. 

MEDePass  Inc.  is  a new,  for-profit  company 
backed  by  the  California  Medical  Association, 
which  will  offer  "digital  certificates"  to  doctors 
and  health  professionals  nationwide,  enabling 
them  to  communicate  securely  over  the  Internet. 
Once  the  credentialing  process  is  completed, 
MEDePass  will  issue  the  certificates  through  an 
alliance  with  Internet-security  company, 
VeriSign,  Inc.  The  certificates  — computer  files 
that  act  as  electronic  identification  cards  or  sig- 
natures — allow  participants  to  send  informa- 
tion to  patients  or  to  identify  themselves  online 
when  buying  regulated  supplies. 

http:/  / www.medepass.com 

The  American  Medical  Association  Credential 
Management  System  (CMS),  with  computer- 
chip  maker  Intel  Corp.,  is  addressing  the  secu- 
rity issues  by  offering  its  own  online  digital  ID 
system  for  physicians. 

There  is  no  perfect  answer  to  virus  threats  to 
your  computer,  but,  just  as  we  have  vaccinations 
and  antibiotics,  so  too  is  the  "antidote"  effort 
continuing  to  treat  the  spread  of  these  other  in- 
vaders. To  help  ensure  a safe  and  productive 
Internet  experience  for  you  and  your  family, 
there  are  a variety  of  "providers"  who  offer  prod- 
ucts to  check  whether  your  computer  is  pro- 
tected from  inappropriate  content,  viruses,  pri- 
vacy threats,  and  hackers  (computer  "burglars"). 

You  can  receive  further  help  and  informa- 
tion from  at  least  the  following  sources: 

McAfee.com: 

http:/  / www.mcafee.com 


Norton  (Symantec): 

http:  / / securityl.norton.com 
Dr  Solomon  VirusScan: 

http:/  / www.drsolomons.com 
Symantec: 

http:/  / www.symantec.com 
A list  of  Anti-Virus  updates  is  available  over  the 
Internet. 

http:/  / www.cert.org 

OTHER  “SECURITY”  ISSUES 

DOCUSEARCH.COM  is  a Web  site  dedicated 
to  finding,  locating,  tracing,  or  tracking  down 
anybody,  or  his  or  her  private  information,  such 
as  their  Social  Security  Number!  They  offer  a 
wide  variety  of  locate  searches,  DMV  driver  and 
vehicle  searches,  telephone  record  searches, 
financial  searches,  plus  criminal  records,  civil 
and  court  records,  and  property  records,  for  a 
FEE.  This  kind  of  potential  for  privacy  abuse  is 
frightening  in  its  implications  for  health  care,  as 
well  as  these  other  areas  of  confidentiality 
concerns. 

http:/  / www.docusearch.com 

The  Internet  Fraud  Complaint  Center  is  a Web 
site  partnership  between  the  Federal  Bureau  of 
Investigation  (FBI)  and  the  National  White  Col- 
lar Crime  Center  (NW3C)  for  reporting  sus- 
pected Internet  fraud.  It  provides  a convenient 
and  easy-to-use  reporting  mechanism  that  alerts 
authorities  of  a suspected  criminal  or  civil  vio- 
lation. 

http://www.ifccfbi.gov 

PERSONAL  OR  OFFICE  WEB  SITES 

Having  your  own  Web  site  can  improve  office 
efficiency  and  strengthen  patient  relationships. 

It  can  provide  the  viewer  with:  information 
concerning  your  practice  and  your  credentials, 
a map  to  your  office(s),  educational  handouts, 
pre-  and  post-op  instructions,  and  links  to  other 
Web  sites. 

Medem  Inc.  is  an  Internet  health  company 
owned  by  the  AMA,  American  Academy  of  Pe- 


J La  State  Med  Soc  VOL  152  September  2000  451 


diatrics,  American  Academy  of  Ophthalmology, 
American  Society  of  Plastic  Surgeons,  American 
College  of  Allergy,  Asthma  and  Immunology, 
American  College  of  Obstetricians  and  Gyne- 
cologists, and  the  American  Psychiatric  Associa- 
tion. It  offers  credible,  comprehensive,  and  clini- 
cal health  care  information  from  both  an 
individuaPs  own  physician  and  the  nation's 
trusted  medical  societies, 
http:  / / www.medem.com 

Your  Practice  Online  is  a subsidiary  of  Medem 
Inc.,  which  will  allow  physicians  to  create  a per- 
sonalized Web  site  that  provides  critical  infor- 
mation to  patients.  Making  changes,  additions, 
and  updates  to  your  content  is  easy, 
http:  / / www.medem.com/  ypol 

Physicians  On  Line  (POL)  allows  physicians  to 
design  their  own  Web  site  through  a subsidiary, 
mydoctor.com.  It  enables  providing  information 
and  e-commerce  services  for  consumers,  and  it 
gives  patients  and  doctors  a mechanism  for  se- 
cure communication  for  interacting  and  sharing 
information. 

http:/  / www.pol.com 
http:  / / www.mydoctor.com 

NEW  MEDICAL  INTERNET  USES 

For  all-day,  uninterrupted  access  to  cyberspace, 
without  the  delays  in  dialing,  the  "busy"  signals 
by  your  ISP,  or  the  relatively  slow  downloading 
of  data,  consider  subscribing  to  a cable  or  tele- 
phone digital  subscriber  line.  The  monthly  con- 
tract covers  Internet  access  and  e-mail.  The  new 
telephone  broadband  modality  allows  you  to  use 
the  same  telephone  line  at  your  home  or  office 
without  disrupting  the  routine  function,  ie,  talk- 
ing on  the  phone  while  using  the  Internet.4  The 
"surfing"  speed  is  vastly  faster. 

The  Internet  currently  can  enable  physicians 
to  conduct  daily  transactions  with  pharmacies, 
laboratories,  hospitals,  patients,  and  insurers. 

New  entities  are  now  coming  "online"  that 
seek  to  "bypass"  typical  "health  insurers"  by 
allowing  patients  to  customize  their  own  health 


care  product.  One  such,  in  development,  is 
Vivius.com,  which  will  permit  employer  groups 
to  establish  an  annual  health  care  spending  ac- 
count for  each  employee.  The  employees  then 
access  the  Vivius.com  Web  site  and  follow  a 
simple  selection  process,  choosing  their  personal 
physician,  approximately  15  specialist  physi- 
cians, hospital,  medical  laboratory,  radiology 
clinic,  and  pharmacy  network.  The  Vivius  cus- 
tomers not  only  will  create  customized  health 
care  provider  panels  for  themselves  and  each 
covered  family  member,  but  also  will  choose  the 
levels  of  out-of-pocket  co-payment  they're  will- 
ing to  pay  for  care. 

http:  / / www.vivius.com 

"About  25  percent  of  the  estimated  $1  trillion 
spent  annually  on  health  care  in  the  United  States 
is  lost  to  administrative  and  clinical  waste",  says 
Lee  N.  Newcomer,  MD,  executive  vice  president 
and  chief  medical  officer  of  Vivius,  Inc.  "Much 
of  that  waste  is  from  claims  processing,  requir- 
ing referrals  to  specialists,  and  reviewing  re- 
quests for  treatment.  The  Vivius  personalized 
health  care  system  eliminates  all  of  those  waste- 
ful procedures."5 

Clinical  Conferences  or  Medical  Society 
Committee  meetings  will  soon  be  conducted  via 
computer  rather  than  by  telephone  or  "in  per- 
son". Usage  of  currently  available,  inexpensive, 
digital  cameras  and  multiple  "screens"  on  the 
computer  monitor  will  enable  visualization  of 
all  participants  during  these  meetings. 

MyLabCenter.com  is  a new  Web  site  from 
Quest  Diagnostics,  Inc.,  in  partnership  with 
Caresoft  Inc.'s  Web  site.  It  will  offer  patients  the 
ability  to  obtain  their  laboratory  test  results  via 
the  Internet  in  a "secure"  fashion,  along  with 
patient-friendly  information  to  help  them  under- 
stand their  results  with  easy-to-understand  in- 
formation written  by  health  care  professionals. 
These  results  will  be  available  online  to  patients 
who  receive  selected  medical  laboratory  tests 
through  Quest  Diagnostics  Incorporated  (includ- 
ing laboratories  formally  known  as  SmithKline 
Beecham  Clinical  Laboratories).  Patients  will 
also  receive  an  e-mail  with  a link  to  the  specific 


452  J La  State  Med  Soc  VOL  152  September  2000 


Web  page  where  they  can  access  their  results. 
The  e-mail  will  be  sent  4 or  more  days  after  the 
physician  has  received  their  results,  giving  an 
opportunity  to  first  review  the  results  and  con- 
tact the  patient  if  so  chosen.  Results  are  not  pro- 
vided online  for  some  tests  such  as  pathology, 
HIV,  pregnancy,  or  drug  screens, 
http:  / / www.MyLabCenter.com 
http:/  / www.TheDailyApple.com 

ProxyMed  is  a secure  online  tool  for  checking  a 
patient's  insurance  eligibility,  receiving  a 
patient's  laboratory  results,  sending  in  prescrip- 
tions to  contracting  pharmacies,  checking  poten- 
tial drug  interactions,  receiving  suggestions  on 
drugs  that  are  covered  by  a patient's  payer,  re- 
ceiving easy-to-read  patient  drug  guides,  and 
more. 

http:/  / www.proxymed.com 

The  ePhysician.com  product  allows  physicians 
to  securely  send  prescriptions  from  their  Palm 
handheld  computer  to  the  pharmacy  over  the 
Internet.  It  enables  writing  prescriptions  within 
3 seconds  and  multiple  prescriptions  in  one  step. 
You  can  access  information  for  over  4500 
commercially  prescribed  formulations  and 
create  your  own  customized  drug  list  and 
favorite  prescription  list. 

http:/  / www.ephysician.com 
http:  / / www.palm.com 

In  the  realm  of  advertising,  there  is  MedNA,  a 
"Yellow  Pages"  listing  of  physicians, 
http:  / / www.medna.com 

EduNet  Programs  delivers  AMA  and  academi- 
cally accredited  continuing  medical /health  edu- 
cation courses  for  medical /health  professionals 
as  well  as  patient  education  information  and 
courses. 

http:/  / www.edunetprograms.com 

A sobering  quote  appeared  in  the  New  England 
Journal  of  Medicine  from  Dr  Jerome  Kassirer, 
"Online,  computer-assisted  communication  be- 
tween patients  and  medical  data  bases,  and  be- 


tween patients  and  physicians,  promises  to  re- 
place a substantial  amount  of  the  care  now  de- 
livered in  person."* 6 

SUMMARY 

This  article's  illustration  of  some  of  the  many 
uses  of  the  Internet  available  to  Louisiana 
physicians  has  endeavored  to  stimulate  more  of 
our  colleagues  to  embrace  this  technology. 
Perhaps  it  may  even  offer  helpful  information 
to  some  of  our  "Internet  literate"  current  users. 
The  potential  of  this  modality  is  truly 
unfathomable,  and  each  day  new  and  exciting 
functions  become  available. 

REFERENCES 

1.  Laing  JR.  Can  Managed  Care  Be  Saved?  Wall  Street 
Journal  May  15,  2000. 

2.  Waguespack  R.  AAO-HNS  and  academynet:  your 
Internet  partners.  AAO-HNS  BULLETIN 
2000;19(5):13. 

3.  Chesanow  N.  Save  thousands  a year  on  medical 
supplies.  Med  Leon  May  8,  2000:55-71. 

4.  Kraft  S.  Tired  of  waiting  for  the  Web?  Get  connected 
fast.  Med  Leon  May  8,  2000:33-37. 

5.  Introducing  a brand-new  healthcare  concept:  the 
management  of  care  goes  back  to  the  patient  and 
physician.  MINNEAPOLIS  May  12,  2000. 

6.  Kassirer  J.  The  Internet  is  revolutionizing  the 
delivery  of  healthcare.  N Engl  J Med  1995;332:52- 
54. 


Dr  Ellis  is  a clinical  professor  of  Otolaryngology-Head 

& Neck  Surgery,  LSU  School  of  Medicine, 
a Past-President  of  the  Louisiana  State  Medical  Society, 
and  currently  serves  as  a Delegate  to  the 
American  Medical  Association.  He  practices  at  the 
Chalmette  Medical  Center,  Lakeland  Hospital  and 
Pendleton  Methodist  Hospital  in  New  Orleans,  Louisiana. 


J La  State  Med  Soc  VOL  152  September  2000  453 


Providing  Access  to  Prescription  Drugs 
for  America’s  Retirees 

Bobby  Jindal 


Designing  a modern  health  care  pro- 
gram today  without  prescription  drugs 
would  be  unthinkable  and  very  un- 
popular. Prescription  drugs  help  us  live  longer 
and  healthier  lives,  and  yet  Medicare  - the 
country's  largest  health  program  - does  not 
cover  most  outpatient  prescription  drugs.  There 
are  several  plans  now  being  considered  in  Con- 
gress to  increase  access  to  drug  coverage  for 
seniors,  and  the  details  of  how  those  plans  dif- 
fer are  important. 

Today,  prescription  drugs  are  available  to 
help  fight  almost  any  disease,  and  hundreds  of 
new,  more  effective  medicines  are  being  devel- 


oped every  year.  That  is  good  news  for  modern 
medicine,  but  can  sometimes  be  a mixed  bless- 
ing for  the  nearly  40  million  Americans  who  are 
aged  65  or  older.  Medicare  is  still  largely  based 
on  the  1965  model  when  surgery  and  extended 
hospital  stays  were  the  mainstays  of  "modern" 
medicine. 

Today,  unlike  1965,  over  80  percent  of  Medi- 
care beneficiaries  use  at  least  one  prescription 
drug  on  a regular  basis.  And  the  vast  majority 
of  health  plans  for  persons  under  65  cover  pre- 
scription drugs.  There  are  many  reasons  why 
Medicare  has  not  been  restructured  to  keep  up 
with  the  changes  in  modern  health  care.  For  ex- 


454  J La  State  Med  Soc  VOL  152  September  2000 


ample,  policymakers  have  prioritized  prevent- 
ing the  insolvency  of  Medicare's  trust  fund  to 
protect  existing  benefits  and  recipients.  Also, 
current  rules  require  a literal  "Act  of  Congress" 
to  modernize  the  Medicare  program. 

The  National  Bipartisan  Commission  on  the 
Future  of  Medicare,  chaired  by  Senator  John 
Breaux  (D-LA)  and  Representative  Bill  Thomas 
(R-CA),  looked  at  several  ways  the  Medicare  pro- 
gram would  have  to  be  modernized  to  prepare 
it  for  the  twenty-first  century  and  for  the  grow- 
ing number  of  retirees  from  the  Baby  Boom  gen- 
eration. 

A bipartisan  majority  of  the  Commission 
members,  including  the  Chairmen,  concluded 
that  the  Medicare  program  had  grown  overly  bu- 
reaucratic with  its  130,000  pages  of  rules  and 
regulations  and  needed  to  be  made  more  effi- 
cient to  reduce  fraud  and  waste.  A majority  also 
concluded  that  retirees  need  better  access  to  pre- 
scription drugs,  funded  in  part  through  the  sav- 
ings generated  by  the  restructuring.  Indeed,  both 
Sen.  Breaux  and  Rep.  Thomas  have  been  lead- 
ers in  the  effort  to  modernize  Medicare  and  to 
increase  access  to  prescription  drugs. 

The  prescription  drug  discussion  is  an  im- 
portant public  debate,  and  it  is  one  that  should 
be  watched  carefully.  The  issues  and  even  lan- 
guage are  complex,  but  there  are  guideposts  that 
can  help  regular  citizens  follow  the  debate.  I am 
writing  to  share  the  following  checklist  of  10  cri- 
teria that  can  be  used  in  evaluating  any  prescrip- 
tion drug  plan  for  seniors.  These  criteria  were 
compiled  after  listening  to  a variety  of  experts, 
organizations  and  health  care  professionals: 

1.  Does  the  plan  prioritize  access  to  prescrip- 
tion drugs  for  those  persons  who  need  them 
most  (the  sickest  and  poorest)?  Surveys  indi- 
cate that  retirees  are  willing  to  help  pay  for  this 
important  health  benefit,  as  long  as  the  costs  are 
reasonable.  Both  Republican  and  Democratic 
plans  being  considered  in  Congress  include 
some  limited  subsidy  for  all  seniors,  but  it  also 
makes  sense  to  focus  scarce  resources  on  those 
most  in  need  and  to  customize  drug  coverage  to 
meet  the  particular  needs  of  each  individual. 
Nearly  two-thirds  of  Medicare  beneficiaries  have 


some  access  to  prescription  drug  coverage,  al- 
though it  is  sometimes  limited  and  shrinking. 
Given  the  high  cost  of  prescription  drugs,  some 
beneficiaries  without  adequate  coverage  may 
forgo  or  ration  drugs  because  they  cannot  afford 
the  expense  - a medically  risky  practice;  benefi- 
ciaries with  drug  coverage  average  20  prescrip- 
tions per  year  compared  to  15  for  those  without 
coverage.  It  should  not  be  surprising  that  seniors 
earning  $50,000  or  more  are  almost  twice  as 
likely  as  seniors  earning  less  than  $10,000  to  have 
drug  coverage  currently;  at  the  same  time,  nearly 
60  percent  of  seniors  without  drug  coverage  earn 
less  than  twice  the  poverty  level.  While  seniors 
average  total  prescription  drug  expenditures  of 
over  $600,  7 percent  have  drug  costs  exceeding 
$1,000,  and  19  percent  incur  no  expenditures. 

2.  Does  the  plan  prevent  government  waste 
by  guarding  against  duplication  of  services? 

Congress  has  cited  higher  than  expected  Medi- 
care savings  and  federal  surpluses  to  set  aside 
funds  for  a drug  benefit  without  increasing  taxes. 
It  will  be  important  for  any  new  benefit  to  avoid 
requiring  seniors  with  existing  coverage  to  pay 
higher  premiums  for  duplicate  benefits.  New 
benefits  and  any  associated  costs  must  be  vol- 
untary. Some  analysts  cite  seniors'  anger  over 
paying  for  duplicate  benefits  as  the  cause  of 
Congress's  quick  repeal  of  new  Medicare  ben- 
efits enacted  in  the  late  1980's. 

3.  Will  private  contributions  and  supplemen- 
tal health  care  plans  (such  as  employer-spon- 
sored plans  for  retirees)  continue  to  provide 
funding  and  benefits?  Private  plans  and  con- 
tributors should  continue  to  participate,  instead 
of  pulling  out  and  leaving  the  Medicare  Trust 
Fund  and  taxpayers  to  pay  all  the  medical  costs. 
On  the  other  hand,  the  federal  government 
should  not  create  an  expensive  mandate  for  state 
governments,  private  employers,  or  individual 
retirees. 

4.  Does  the  plan  increase  the  purchasing 
power  of  the  elderly?  The  program  should  of- 
fer seniors  price  breaks,  good  selection  and  vol- 
ume buying  power  similar  to  the  benefits  of 

J La  State  Med  Soc  VOL  152  September  2000  455 


other  health  plans.  House  Republicans  cite  Con- 
gressional Budget  Office  estimates  that  offering 
seniors  access  to  this  purchasing  power  could 
save  seniors  at  least  25  percent.  Already,  some 
seniors  in  border  states  are  traveling  to  Canada 
or  Mexico  to  buy  lower  priced  prescription 
drugs. 

5.  Can  seniors  choose  the  coverage  that  meets 
their  needs?  A one-size-fits-all  approach  is  not 
how  working  Americans  receive  their  health 
benefits,  and  does  not  adequately  address  a large 
population  with  diverse  needs.  There  must  be 
some  protection  of  the  core  value  of  any  drug 
benefit,  with  flexibility  for  seniors  to  adapt  drug 
coverage  to  meet  their  particular  needs. 

6.  Will  the  plan  allow  seniors  to  integrate  pre- 
scription drugs  into  a comprehensive  treatment 
package?  Private  insurance  companies  typically 
"bundle"  drug,  hospital,  and  physician  benefits, 
and  seniors  should  have  access  to  integrated 
plans  that  take  advantage  of  the  efficiencies  of 
combining  the  best  treatment  options.  Unlike 
private  insurance.  Medicare  continues  the  1960's 
practice  of  charging  separate  deductibles  for 
hospital  and  physician  coverage.  Retirees  should 
not  be  forced  to  choose  one  treatment  option 
over  another  based  solely  on  financial,  rather 
than  clinical,  considerations. 

7.  Will  the  plan  protect  seniors  from  the  over- 
whelming costs  of  catastrophic  illnesses?  Pre- 
scription drugs  are  becoming  more  effective  and 
expensive,  and  it  will  be  more  important  for  se- 
niors to  have  access  to  comprehensive  coverage 
rather  than  limiting  them  to  coverage  that  pays 
only  for  routine  treatments  and  small  expenses. 

8.  Does  the  plan  avoid  unnecessary  govern- 
ment regulation  and  price  controls?  The  pri- 
vate sector  has  been  the  leader  in  benefit  man- 
agement, and  the  government's  size  will  prevent 
it  from  matching  this  flexibility.  The  government 
is  already  the  largest  single  purchaser  of  health 
care  services,  and  the  Medicare  and  Medicaid 


programs'  combined  market  share  makes  many 
hospitals  and  other  providers  almost  entirely 
dependent  on  government  coverage  decisions. 
It  will  be  important  to  provide  seniors  access  to 
modern  treatments  without  distorting  the  mar- 
ket or  otherwise  reducing  the  incentives  for  com- 
panies to  invest  the  millions  of  dollars  it  takes 
to  develop  a single  drug. 

9.  Does  the  prescription  drug  benefit  remain 
affordable  for  everyone?  Drug  coverage  will 
not  help  those  retirees  who  need  access  the  most, 
if  plans  are  only  affordable  for  the  younger  and 
healthier  retirees.  The  health  insurance  market 
often  separates  rather  than  combining  risk;  it  is 
especially  important  to  avoid  this  tendency  to 
raise  premiums  or  drop  coverage  when  seniors 
need  access  to  drugs  the  most.  This  can  be  ac- 
complished through  some  combination  of  rein- 
surance, high-risk  pools,  guaranteed  renewal,  or 
many  other  policy  options. 

10.  Does  the  plan  encourage  Medicare  modern- 
ization? Adding  prescription  drug  coverage 
must  be  done  in  a way  that  encourages  contin- 
ued modernization  and  improvement  of  the 
overall  program.  Without  fundamental  reform, 
cutting  one  group  of  providers  and  beneficia- 
ries merely  to  add  new  benefits  or  help  another 
group  will  not  provide  seniors  with  access  to 
modern,  high-quality  health  care  to  meet  their 
changing  needs.  As  the  Commission  Chairmen 
often  stated,  putting  new  gas  into  an  old  car  will 
not  necessarily  make  it  run  any  better. 

The  ongoing  national  debate  about  the  modern- 
ization of  Medicare  is  important  to  every  Ameri- 
can, regardless  of  age.  Medicare  is  a program 
that  has  served  the  health  needs  of  millions  of 
persons  since  its  creation  in  1965,  and  millions 
of  others  are  counting  on  its  benefits  when  they 
retire.  Today,  Medicare  needs  our  collective 
ideas,  voices  and  attention  to  ensure  that  its 
modernization  truly  matches  the  needs  of  ever- 
changing  healthcare  technology,  workforce,  eco- 
nomic base  and  beneficiaries. 


456  J La  State  Med  Soc  VOL  152  September  2000 


CHECKLIST 

Evaluating  Prescription  Drug  Plans 


The  following  checklist  is  designed  to  help  evaluate  proposed  prescription  drug  plans  for  retirees.  These  criteria 
were  compiled  from  a variety  of  experts,  organizations  and  medical  professionals. 

Does  the  plan  . . . 

• Prioritize  access  to  prescription  drugs  for  those  persons  who  need  them  most  (the  sickest  and  poorest)? 

• Prevent  government  waste  by  guarding  against  duplication  of  services? 

• Ensure  that  private  contributions  and  supplemental  health  care  plans  (such  as  employer-sponsored 
plans  for  retirees)  continue  to  provide  funding  and  benefits? 

• Increase  the  purchasing  power  of  the  elderly? 

• Allow  seniors  to  choose  the  coverage  that  meets  their  needs? 

• Offer  seniors  prescription  drugs  as  part  of  a comprehensive  treatment  package? 

• Protect  seniors  from  the  overwhelming  costs  of  catastrophic  illnesses? 

• Avoid  unnecessary  government  regulation  and  price  controls? 

• Ensure  that  the  prescription  drug  benefit  remains  affordable  for  everyone? 

• Encourage  Medicare  modernization? 


Mr  Jindal  was  Secretary  of  Louisiana's 
Department  of  Health  and  Hospitals  from 
January  1996  to  February  1998  and  served  as 
Executive  Director  of  the  National  Bipartisan 
Commission  on  the  Future  of  Medicare.  He  is  now  the 
President  of  the  University  of  Louisiana  System. 


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October  2000 


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8:00  am 

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J La  State  Med  Soc  VOL  152  September  2000  459 





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460  J La  State  Med  Soc  VOL  152  September  2000 


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Special  Issue:  Adolescent  Violence 


Proven  Practices  for  Reducing  Aggressive  and  Noncompliant  Behaviors  Exhibited  by  Young  Chiidren 
A Developmental  Psychopathology  Approach  to  Understanding  and  Preventing  Youth  Violence 
The  Effects  of  Community  Violence  Exposure  on  Louisiana’s  Children 
Violence  Prevention:  Myth  or  Reality? 

Children,  Adolescents,  and  Guns  in  Louisiana:  A Thought  Experiment 
ECG  of  the  Month:  Give  P’s  a Chance 

Otolaryngology  Case  of  the  Month:  Medical  Management  of  Pediatric  Chronic  Sinusitis 

Radiology  Case  of  the  Month:  A Groin  Mass 
History  of  Medicine:  Walker  Percy’s  Magic  Mountain 


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Practice  Accredited  by  the  American  College  of  Radiology 


NOW  OPEN  - AVENUE  C / MARRERO  LOCATION 


Editor 

CONWAY  S.  MAGEE,  MD 

Chief  Executive  Officer 

DAVE TARVER 

General  Manager 

CATHY  LEWIS 

Managing  Editor 

ANNE  SHIRLEY 

Administrative  Assistant 

MELISSA  CANTRELL 

Advertising  Sales 

ANNE  GOOCH 


Of  the  Louisiana  State  Medical  Society 


BOARD  OF  TRUSTEES 
Chairman,  CONWAY  S.  MAGEE,  MD 
K.  BARTON  FARRIS,  MD 
Ex  officio,  C.  Clinton  Lewis,  MD 

EDITORIAL  BOARD 
A.  JOANNE  GATES,  MD 
RODNEY  C.  JUNG,  MD 
PATRICK  W.  PEAVY,  MD 
TRENTON  L.  JAMES  II,  MD 
JACK  P.  STRONG,  MD 
CLAY  A.  WAGGENSPACK  JR,  MD 
WINSTON  H.  WEESE,  MD 


Special  Issue:  Adolescent  Violence 


Articles 


H.  Jay  Collinsworth,  MD 


483  Adolescent  Violence 


Amanda  VanDerHeyden,  MA 
Joseph  C.  Witt,  PhD 


485  Proven  Practices  for  Reducing  Aggressive 
and  Noncompliant  Behaviors  Exhibited  by 
Young  Children  at  Home  and  at  School 


LSMS  BOARD  OF  GOVERNORS 
C.  CLINTON  LEWIS,  MD 
DUDLEY  M.  STEWART,  MD 
KEITH  DESONIER,  MD 
LEO  L.  LOWENTRITT  JR,  MD 
K.  BARTON  FARRIS,  MD 
RUSSELL  C.  KLEIN,  MD 
WALLACE  H.  DUNLAP,  MD 
VINCENT  A.  CULOTTA  JR,  MD 
RICHARD  J.  PADDOCK,  MD 
BARRY  G.  LANDRY,  MD 
WILLIAM  T.  HALL,  MD 
JOSEPH  BUSBY  JR,  MD 
LYNN  Z.  TUCKER,  MD 
R.  MARK  WILLIAMS,  MD 
MARTIN  B.  TANNER,  MD 
MARTIN  J,  DUCOTE  JR,  MD 
MARCUS  L.  PITTMAN  III,  MD 
CHARLES  D.  BELLEAU,  MD 
JOSHUA  LOWENTRITT,  MD 
LAURA  BRESNAHAN  ROBERTS 


Paul  J.  Frick,  PhD 

497 

A Developmental  Psychopathology 
Approach  to  Understanding  and  Preventing 
Youth  Violence 

Nicole  F.  Lanclos,  MA 
Stewart  T.  Gordon,  MD 
Mary  Lou  Kelley,  PhD 

504 

The  Effects  of  Community  Violence 
Exposure  on  Louisiana’s  Children 

Pat  Melton,  LCSW 

509 

Violence  Prevention:  Myth  or  Reality? 

Holley  Galland,  MD 

523 

Children,  Adolescents,  and  Guns 
in  Louisiana:  A Thought  Experiment 

Departments 


ESTABLISHED  1844.  Owned  and  edited  by  the 
Journal  of  the 
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The  Journal  of  the  Louisiana  State  Medical  Society 

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Articles  and  Advertisements  published  in  the  Journal 
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necessarily  represent  the  official  position  or 
endorsement  of  the  Journal  of  the  Louisiana 
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The  Journal  reserves  the  right  to  make  the  final 
decision  on  all  contents  and  advertisements. 


464 

Jorge  I.  Martinez-Lopez,  MD  467 

Lincoln  L.  Lippincott,  MD  470 

Karla  R.  Brown,  MD 


Scott  Wilson,  MD  475 

Rod  Chandler,  MD 
Harold  R.  Neitzschman,  MD 

Laurel  A.  Saunders,  BA  477 

532 

534 


INFORMATION  FOR  AUTHORS 

ECGOFTHE  MONTH 
Give  P’s  a Chance 

OTOLARYNGOLOGY/HEAD  & NECK 
SURGERY  REPORT 
Medical  Management  of  Pediatric 
Chronic  Sinusitis 

RADIOLOGY  CASE  OF  THE  MONTH 
A Groin  Mass 

HISTORY  OF  MEDICINE 
Walker  Percy’s  Magic  Mountain 

CALENDAR 

CLASSIFIED  ADVERTISING 


J La  State  Med  Soc  VOL  152  October  2000 


Information  for  Authors 


The  Journal  is  published  for  the  benefit  of  the  members  of  the  Louisiana  State 
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1.  Brush  JE  Jr,  Cannon  RO  III,  Schenke  WH,  et  al.  Angina  due  to  coro- 
nary microvascular  disease  in  hypertensive  patients  without  left  ven- 
tricular hypertrophy.  N Engl  / Med  1988;319:1302-1307. 

2.  Hajdu  SI.  Patholog y of  Soft  Tissue  Tumors.  Philadelphia,  Pa:  Lea  & 
Febiger;  1979:60-83. 

3.  Robinson  BH.  Lactic  acidemia.  In:  Scriver  CR,  Beaudet  AL,  Sly  WS, 
et  al  (editors).  The  Metabolic  Basis  of  Inherited  Disease,  6th  edition. 
New  York:  McGraw-Hill;  1989:869-888. 

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Editor,  Journal  of  the  Louisiana  State  Medical  Society 
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Baton  Rouge,  LA  70808 


464  J La  State  Med  Soc  VOL  152  October  2000 


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ECG  of  the  Month 


Give  P’s  a Chance 

Jorge  I.  Martinez-Lopez,  MD 


A 55-year-old  homeless  man  presented  to  the  hospital  with  a complex  medical  history.  The 
rhythm  strip  shown  below,  limb  lead  II,  was  recorded  several  hours  after  his  admission  to 


the  MICU. 


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What  is  your  diagnosis? 
Elucidation  begins  on  page  468. 


J La  State  Med  Soc  VOL  152  October  2000  467 


ECG  of  the  Month 
Presentation  is  on  page  467. 

DIAGNOSIS  - Incomplete  AV dissociation 

In  a tracing  such  as  the  one  shown  here,  it  is 
appropriate  to  begin  the  analysis  with  the  third 
and  fourth  cardiac  cycles  in  the  top  panel. 
These  two  cycles  define  the  basic  cardiac 
rhythm:  sinus  bradycardia  at  54  times  a 
minute,  with  a normal  PR  interval  (0.16  sec) 
and  narrow  QRS  complex  (0.09  sec).  Together, 
these  findings  indicate  that  sinus  impulses 
were  conducted  normally  into  and  across  the 
AV  junction  and  the  distal  intraventricular  con- 
ducting system,  and  resulted  in  normal 
biventricular  depolarization.  Abnormal  ven- 
tricular repolarization  is  signalled  by  the  long 
QT  interval.  U waves  that  follow  the  end  of 
the  T wave  may  be  either  a normal  or  an  ab- 
normal finding. 

Some  alterations  of  the  findings  described 
above  appear  after  the  fourth  cycle  in  the  top 
panel:  the  sinus  rate  slows  down  further,  to  about 
45  times  a minute;  PR  intervals  of  subsequent 
cycles  shorten;  and  sinus  Ps  gradually  move  to- 
ward and  into  the  ventricular  complexes.  At  the 
same  time  that  these  changes  take  place,  the  R- 
R intervals  lengthen,  also  after  the  fourth  cycle. 
Although  the  ventricular  rate  is  now  slower,  it 
is  both  regular  and  independent  of  the  advanc- 
ing P waves;  QRS  complexes  of  this  slower 
rhythm  remain  identical  in  configuration  to 
those  of  the  sinus  cycles  and  can  be  judged  to 
originate  in  the  AV  junctional  tissues. 

Similar  ECG  phenomena  are  found  in  the 
middle  panel.  Here,  no  clear-cut  P wave  is  re- 
corded in  the  first  cycle;  the  sinus  P is  concealed 
within  the  QRS  complex.  In  subsequent  cycles, 
sinus  Ps  move  either  towards  or  away  from  the 
QRS.  By  the  sixth  and  seventh  cycles  however, 
sinus  Ps  are  replaced  by  inverted  P waves  (PC) 
with  relatively  normal  PCR  intervals;  such  PC 
waves  are  consistent  with  a slow,  ectopic  rhythm 
arising  from  either  the  low  atrium  or  the  AV  junc- 


tion. Although  P waves  remain  inverted  in  the 
bottom  panel,  they  display  shorter  and  variable 
PCR  intervals,  compared  to  the  last  two  cycles  in 
the  middle  panel. 

It  is  now  possible  to  synthesize  the  above 
findings  as  follows.  The  basic  cardiac  rhythm  is 
sinus  bradycardia.  As  the  sinus  rate  slows  down 
further,  an  AV  junctional  escape  rhythm  surfaces 
and  competes  with  the  sinus  node  for  domi- 
nance over  the  ventricles.  Because  the  AV  junc- 
tional escape  rhythm  is  faster  than  the  sinus  rate, 
it  succeeds  in  producing  biventricular  depolar- 
ization. As  long  as  the  escape  rhythm  remains 
as  the  dominant  pacemaker,  atrial  and  ventricu- 
lar activity  are  independent  of  each  other.  Be- 
cause the  sinus  node  has  defaulted  in  its  role  as 
the  dominant  cardiac  pacemaker,  this  type  of  dis- 
sociation is  termed  AV  dissociation  by  default.  The 
term  AV  dissociation  (AVD)  is  not  a complete  or 
final  ECG  diagnosis  in  any  given  tracing. 

Although  it  is  descriptive  of  the  indepen- 
dent activities  of  the  atria  and  the  ventricles, 
many  different  rhythm  disorders  may  be  respon- 
sible for  producing  AVD.  Therefore,  AVD  is  al- 
ways the  end  result  of  other  primary  rhythm 
disorders. 

Because  AVD  is  secondary  to  a primary 
rhythm  disorder,  a determination  of  its 
electrophysiologic  mechanism  and  a search  for 
its  cause  must  be  undertaken.  In  general,  AVD 
may  be  produced  by  the  following  primary 
rhythm  disorders.  First,  AVD  by  default  occurs 
when  the  sinus  rate  slows  down  to  such  an  ex- 
tent that  it  allows  a secondary  pacemaker  firing 
at  a faster  rate  than  that  of  the  sinus  node  to  be- 
come dominant.  Second,  AVD  by  usurpation  oc- 
curs when  a subsidiary  pacemaker,  ordinarily 
subservient  to  the  sinus  rhythm,  fires  at  much 
faster  rate  than  the  sinus  node  (for  example,  in 
ventricular  tachycardia).  Complete  AV  block,  the 
third  type  of  AVD,  may  be  congenital  or  acquired, 
and  either  permanent  or  transient.  The  fourth 
mechanism  responsible  for  AVD  is  a cardiac  pace- 
maker-induced  ventricular  rhythm.  In  a rare  patient, 
a combination  of  the  above  mechanisms  may  be 
responsible  for  AVD.  Incomplete  forms  of  AVD 
are  found  when  any  sinus  impulse  is  conducted 


468  J La  State  Med  Soc  VOL  152  October  2000 


into  the  ventricles,  even  once,  during  AVD. 

During  AVD  by  default,  the  duration  of  the 
QRS  defines  the  location  of  the  escape  rhythm. 
Narrow  QRS  complexes  indicate  a supraven- 
tricular location,  either  in  the  AV  junction  or  the 
bundle  of  His.  Wide  QRS  complexes,  in  contrast, 
may  occur  in  response  to  supraventricular  im- 
pulses conducted  abnormally  into  the  ventricles 
or  to  ventricular  ectopic  activity. 

Determination  of  the  electrophysiologic 
mechanism  responsible  for  AVD  is  useful  in  nar- 
rowing down  its  causes.  In  the  tracing  shown 
here,  AVD  emerged  because  of  the  profound 
slowing  of  the  sinus  rate,  defaulting  its  domi- 
nance to  a subsidiary  pacemaker.  Given  this  sce- 
nario, pertinent  questions  relative  to  causes  of 


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inappropriate  slowing  of  the  sinus  rate  must  be 
raised.  Is  the  slowing  drug-induced?  Is  there  a 
cardiac  or  non-cardiac  cause  for  depression  of 
sinus  nodal  electrical  activity?  Could  these  ab- 
normalities result  from  sinus  node  dysfunction? 
With  answers  to  these  and  other  questions,  thera- 
peutic strategy  can  be  planned.  Reversible 
causes  of  inappropriate  sinus  bradycardia 
should  be  eliminated,  if  possible.  Temporary 
cardiac  pacing  for  AVD  by  default  is  not  always 
indicated,  but  should  be  a consideration  when 
a faster  ventricular  rate  is  desirable  to  relieve 
symptoms  or  when  hemodynamic  instability 
indicates  that  restoration  of  normal  AV  syn- 
chrony is  advantageous. 

Multiple  serious  medical  problems  were 
found  in  this  patient,  including  drug,  alcohol, 
and  tobacco  abuse,  cirrhosis  of  the  liver,  and  he- 
patic encephalopathy,  to  name  a few.  Aggressive 
medical  therapy  effected  clinical  improvement. 
As  his  clinical  status  improved,  AVD  disap- 
peared, the  QT  interval  became  normal,  and  the 
U waves  disappeared. 

In  most  instances  of  AVD  by  default,  it  is 
possible  to  "give  Ps  a chance"  to  be  conducted 
into  the  ventricles  simply  by  increasing  the 
rate  of  firing  of  the  SA  node.  When  this  hap- 
pens, AVD  disappears. 


Dr  Martinez-Lopez  is  a specialist  in  cardiovascular 
diseases  affiliated  with  the  Cardiology  Service,  Department 
of  Medicine,  Texas  Tech  University  Health  Sciences  Center 
and  Thomason  General  Hospital  in  El  Paso,  Texas. 


J La  State  Med  Soc  VOL  152  October  2000  469 


Otolaryngology/ 




Medical  Management  of 
Pediatric  Chronic  Sinusitis 


Lincoln  L.  Lippincott,  MD  and  Karla  R.  Brown,  MD 


Pediatric  sinusitis  can  be  a challenging  disease  to  treat,  whether  by  a primary  care  physician 
or  an  otolaryngologist.  When  initial  appropriate  therapy  fails  to  resolve  the  disorder,  frustra- 
tion may  develop  on  the  part  of  the  patient,  the  family,  and  the  physician.  In  addition  to 
treatment  with  appropriate  antibiotics  for  a sufficient  length  of  time,  other  associated  condi- 
tions that  can  exacerbate  the  condition  must  be  considered  and  addressed  as  necessary.  These 
may  include  viral  upper  respiratory  infections,  allergic  rhinitis,  immune  deficiencies,  asthma, 
and  gastroesophageal  reflux  disease.  Unless  all  associated  conditions  have  been  optimized, 
treatment  of  chronic  sinusitis  will  often  be  unsuccessful.  Recognition  that  there  may  be  an- 
other factor  contributing  to  the  patient's  continuing  illness  should  prompt  appropriate  evalu- 
ation and  occasionally  referral  to  appropriate  specialists.  Except  for  the  unusual  pediatric 
patient  with  a truly  anatomic  disorder  or  an  underlying  chronic  illness  such  as  cystic  fibrosis, 
proper  medical  management  will  almost  always  resolve  chronic  sinusitis. 


asymptomatic  between  these  exacerbations.  This 
months.1  A nighttime  cough  is  a common  com-  should  be  differentiated  from  recurrent  acute 

plaint  and  is  usually  more  prevalent  than  a day-  sinusitis,  in  which  complete  resolution  takes 

time  cough.  In  addition,  chronic  symptoms  of  place  between  episodes  and  different  treatment 

nasal  discharge  and  congestion  are  also  com-  options  apply.2  It  is  very  uncommon  for  a pa- 

plaints.  Headaches,  although  common  in  older  tient  with  chronic  sinusitis  to  present  in  a toxic- 

children  with  chronic  sinusitis,  may  be  difficult  appearing  state  or  with  complications.  However, 

to  appreciate  in  a younger  pediatric  patient  who  increasing  purulent  rhinorrhea,  temperature 

may  instead  have  difficulties  with  behavior  and  above  39°C  and  periorbital  edema,  when 

irritability.  Although  more  severe  acute  sinusi-  present,  may  herald  an  impending  complication. 


Ihronic  sinusitis  is  defined  as  a low-grade  tis  symptoms  may  exacerbate  a course  of  chronic 

persistence  of  the  signs  and  symptoms  sinusitis,  these  patients  are  never  completely 


470  J La  State  Med  Soc  VOL  152  October  2000 


Table  1 . Signs  and  symptoms  of  pediatric  sinusitis3 

Rhinorrhea 

Infrequent,  low-grade  fever 

Cough 

Otitis  media  in  50%  to  60% 

Nasal  congestion 

Irritability  or  headache 

PHYSICAL  EXAMINATION  AND 
INITIAL  TREATMENT 

When  examining  a patient  with  a history  sug- 
gestive of  chronic  sinusitis,  one  should  carefully 
examine  the  entire  patient.  The  otoscopic  exami- 
nation, nasal  examination,  and  chest  ausculta- 
tion are  essential.  Anterior  rhinoscopy  with  a 
nasal  speculum,  especially  after  topical  decon- 
gestion, will  allow  examination  of  the  middle 
turbinate  and  occasionally  the  middle  meatus 
for  evidence  of  purulence  or  sinus  discharge. 
Polyps  are  an  uncommon  finding  in  young  chil- 
dren and  should  prompt  an  evaluation  for  cys- 
tic fibrosis.4  Unilateral  polyps  are  an  even  more 
unusual  finding  and  should  alert  the  physician 
to  the  possibility  of  a congenital  midline  nasal 
mass.  Nasal  flexible  or  rigid  endoscopy  provides 
an  excellent  look  at  the  middle  meatus  and  gives 
the  most  accurate  examination  we  can  obtain 
outside  of  the  operating  room.  This  is  possible, 
with  patience  and  reassurance,  with  most  chil- 
dren. Transillumination  of  the  sinuses  and  plain 
film  radiographs  are  rarely  helpful,  and  imag- 


ing with  computed  tomography  should  be  de- 
layed until  the  patient  has  undergone  at  least 
one  extended  course  of  maximal  medical 
therapy.  This  includes  appropriate  second-line 
antibiotics  and  possibly  nasal  saline  spray,  topi- 
cal nasal  steroids,  and  decongestants.5 

In  contrast  to  acute  sinusitis,  no  well-de- 
fined bacterial  population  exists  for  chronic  si- 
nusitis (Table  2).  In  fact,  this  is  commonly  a 
polymicrobial  infection.6  Commonly  patients 
have  already  received  multiple  short  courses 
of  antibiotic  therapy.  However,  at  least  3-6 
weeks  of  a broad-spectrum,  beta-lactamase  re- 
sistant, second-line  antibiotic  should  be  given 
in  the  case  of  chronic  sinusitis  where  symptoms 
have  been  consistently  present  for  at  least  3 
months.1  This  should  be  tailored  to  culture  re- 
sults when  they  have  been  properly  obtained 
as  well  as  two  common  pathogens  and  resis- 
tant strains  prevalent  in  the  community.  Medi- 
cal adjuncts  are  often  useful,  especially  short- 
term use  of  topical  decongestants  such  as 
oxymetazoline,  topical  nasal  steroids,  systemic 
decongestants,  mucolytics,  and  saline  irriga- 
tions. The  physician  should  consider  changing 
the  antibiotic  if  there  has  been  no  significant 
response  within  1 week.  It  may  also  be  helpful 
at  this  point  to  obtain  a middle  meatal  swab  or 
maxillary  sinus  culture,  if  this  has  not  already 
been  performed,  in  order  to  more  appropriately 
adjust  antibiotic  coverage. 


Table  2.  Commonly  cultured  bacteria  in  chronic  sinusitis7 


♦ Alpha-hemolytic  streptococcus 

♦ Coagulase-negative  staphylococcus 

♦ Moraxella  catarrhalis 

♦ Anaerobic  bacteria,  including 
peptostreptococcus,  prevotella, 
bacteroides,  fusobacterium 


♦ Staphylococcus  aureus 

♦ Non-typeable  Haemophilus  influenzae 

♦ Pseudomonas 


J La  State  Med  Soc  VOL  152  October  2000  471 


ASSOCIATED  CONDITIONS 

Until  all  exacerbating  medical  conditions  have 
been  evaluated  and  properly  managed,  the  treat- 
ment of  chronic  sinusitis  can  be  very  frustrating 
and  unsuccessful.  In  comparison  to  adult  pa- 
tients with  sinusitis,  the  pediatric  patient  much 
more  commonly  has  other  contributing  factors 
that  are  complicating  the  situation. 

Viral  Upper  Respiratory  Infections 

The  most  significant  predisposing  factor  for  pe- 
diatric sinusitis  is  a viral  upper  respiratory  in- 
fection (URI).  The  average  pediatric  patient  can 
be  expected  to  have  4-7  URIs  per  year.  Daycare 
attendance  is  associated  with  a three-fold  in- 
crease in  the  overall  incidence  of  URIs,  and  the 
complicating  sinus  infections  are  more  often 
found  to  be  secondary  to  bacteria  that  have  be- 
come resistant  to  common  antibiotics.  Hand 
washing  as  well  as  decreasing  the  number  of 
children  in  each  individual  daycare  setting  has 
been  shown  to  aid  in  prevention  of  URI  trans- 
mission. Although  it  may  not  be  feasible  in  all 
families,  it  is  oftentimes  helpful  to  remove  the 
child  from  the  daycare  setting  for  an  extended 
period  of  time  in  order  to  break  the  cycle  of 
chronic  sinusitis. 

Allergic  Rhinitis 

The  second  most  common  predisposing  factor 
for  sinusitis  is  allergic  rhinitis,  affecting  10%  to 
15%  of  the  pediatric  population  over  9 years  of 
age.7  Boggy,  pale  inferior  turbinates  are  a con- 
sistent physical  finding.  Clear  nasal  discharge 
is  commonly  seen  on  anterior  rhinoscopy  as 
well.  These  children  oftentimes  have  complaints 
of  nighttime  cough,  itchy  eyes,  frequent  sneez- 
ing, and  morning  headaches.  A history  of  the 
child  frequently  performing  the  " allergic  salute" 
and  the  presence  of  "allergic  shiners"  increase 
suspicion  of  an  allergic  etiology. 

Eosinophilia  with  the  resultant  increase  in 
major  basic  protein  is  toxic  to  mucosa  and  dis- 
rupts mucociliary  clearance.  This  promotes  stag- 
nant secretions,  increased  bacterial  counts,  in- 
creased mucosal  inflammation,  and  further  dis- 
ruption of  ciliary  function. 


Complete  allergen  avoidance  is  often  not  re- 
alistic. However,  establishing  an  optimal  envi- 
ronment at  home  is  important.  This  is  normally 
guided  by  results  of  allergy  testing  and  may  in- 
clude removing  pets  from  the  home  as  well  as 
measures  to  decrease  dust  mites.  Second-hand 
smoke  exposure  is  one  area  that  should  defi- 
nitely be  addressed  when  optimizing  the  home 
environment  as  we  know  that  it  contributes  sig- 
nificantly to  the  problem  in  these  children. 

Topical  nasal  steroids  and  second-generation 
antihistamines  should  be  given.  Proper  use  of 
nasal  steroids  should  be  explained  to  the  par- 
ent. Complications  such  as  septal  irritation  and 
bleeding  that  decrease  compliance  can  be  de- 
creased with  proper  use  of  the  spray  aimed  at 
the  lateral  nasal  wall  where  the  medication  is 
most  useful.  Daily  use  of  a nasal  steroid  is  also 
very  important  for  it  to  be  therapeutic.  Allergy 
testing  is  recommended  in  cases  that  do  not  re- 
spond to  medical  therapy,  particularly  in  chil- 
dren with  a strong  family  history  or  children 
showing  other  signs  of  atopy,  such  as  urticaria. 
Immunotherapy  may  be  considered  if  specific 
offenders  are  identified  with  skin  testing. 

Immune  Deficiency 

Immunodeficiency  is  present  in  0.5%  of  the  popu- 
lation, more  common  in  the  general  population 
than  cystic  fibrosis  or  ciliary  disorders.  The  most 
common  types  are  common  variable  immuno- 
deficiency, IgG  subclass  deficiency,  and  selective 
antibody  deficiencies.8  As  many  as  one  third  of 
cases  of  refractory  rhinosinusitis  may  involve 
immune  deficiencies,  especially  if  the  patient  has 
a history  of  frequent  bacterial  infections  or  be- 
comes ill  soon  after  antibiotics  are  stopped. 
Evaluation  should  be  reserved  until  an  adequate 
medical  course  of  therapy  for  chronic  sinusitis 
has  proven  not  to  be  effective.  An  appropriate 
initial  evaluation  may  include  obtaining  serum 
immunoglobulin  levels  including  subtypes, 
monitoring  the  patient's  response  to  tetanus  tox- 
oid or  pneumoccoccal  vaccine,  and  referral  to  an 
immunologist.  Immunoglobulin  therapy,  while 
not  without  problems,  can  prove  invaluable  in 
the  treatment  of  these  children. 


472  J La  State  Med  Soc  VOL  152  October  2000 


Asthma 

Impaired  nasal  function  increases  post-nasal 
drip  and  the  irritant  burden  on  the  lower  air- 
ways. This  has  been  shown  to  exacerbate 
asthma  symptoms.  There  is  a well-documented 
association  between  reactive  airway  disease  and 
chronic  rhinitis,  and  treatment  of  one  often  has 
beneficial  effects  on  the  other.4  The  treatment  of 
chronic  sinusitis  can  aid  in  normalization  of  pul- 
monary function  tests  and  the  ability  to  decrease 
chronic  use  of  bronchodilators. 

Gastroesophageal  Reflux 

Clinicians  are  becoming  more  aware  of  gastroe- 
sophageal reflux  (GER)  as  an  etiologic  agent  in 
patients  with  chronic  cough,  hoarseness,  and 
asthma  symptoms.  Gastro-nasal  reflux  is  pos- 
tulated to  induce  inflammation  of  the  eusta- 
chian  tube  orifices  or  sinus  ostia  secondary  to 
mucosal  irritation.9  The  resultant  otitis  media 
or  sinusitis  will  be  difficult  to  treat  and  is  likely 
to  recur  if  GER  is  not  controlled.  Children  with 
a history  of  reflux  as  an  infant  or  who  are  hav- 
ing poor  weight  gain  or  chronic  reactive  airways 
disease  are  especially  suspect.  Evaluation  may 
begin  with  a barium  swallow  and  potentially 
include  a 2-channel  pH  probe,  which  is  the  gold- 
standard  for  diagnosis  of  GER  disease.  Conser- 
vative measures  include  elevating  the  head-of- 
bed,  not  feeding  infants  immediately  prior  to 
bedtime,  and  thickening  feeds.10  An  empiric  trial 
of  antireflux  medications  may  be  considered  in 
children  with  chronic  sinusitis  symptoms  not 
responsive  to  medical  management  and  may  be 
used  as  a diagnostic  tool. 

OTHER  CONSIDERATIONS 

Finally,  more  infrequent  disorders  should  re- 
main in  the  differential  diagnosis.  Anatomic  ab- 
normalities such  as  a large  concha  bullosa  or 
antrochoanal  polyps  can  contribute  to  nasal  ob- 
struction and  sinus  disease.11  Computerized  to- 
mography of  the  sinuses  can  be  helpful  in  this 
evaluation. 

Chronic  disease  that  affects  sinus  mucosal 
function,  such  as  cystic  fibrosis  or  ciliary 


dysmotility  syndromes,  must  also  be  considered. 
Maximal  medical  therapy  can  be  helpful  in  these 
patients,  but  the  benefit  of  frequent  nasal  saline 
irrigations  cannot  be  overemphasized.  Clearing 
the  nose  and  paranasal  sinuses  of  stagnant  secre- 
tions and  decreasing  bacterial  counts  by  mechani- 
cal flushing  decreases  the  frequency  of  symptom- 
atic infections.  There  is  some  suggestion  that  sa- 
line may  also  aid  in  decongestion  of  the  nasal  mu- 
cosa. Many  of  these  children  will  eventually  ben- 
efit from  functional  endoscopic  sinus  surgery  in 
order  to  improve  the  ability  to  effectively  irrigate 
the  sinuses.  In  cystic  fibrosis  patients,  this  has 
been  shown  to  decrease  hospitalization  days  and 
improve  the  quality  of  life.12'14 

Allergic  fungal  sinusitis  is  rare  in  children, 
but  the  diagnosis  is  becoming  more  frequent  as 
we  more  often  recognize  the  disease  entity.  Di- 
agnosis is  made  by  demonstrating  allergic  mu- 
cin— by  demonstrating  eosinophilia  and  fungal 
elements  in  the  mucin  of  these  patients.  This  is 
not  the  same  disease  entity  as  invasive  fungal 
sinusitis  and  normally  progresses  in  an  expansile 
fashion  rather  than  invading  and  destroying  tis- 
sues. CT  evaluation  demonstrates  a heteroge- 
neous expansile  mass  in  the  involved  sinus  and 
has  a very  characteristic  appearance.  Treatment 
is  primarily  surgical,  but  recent  literature  is  be- 
ginning to  support  the  use  of  systemic  antifun- 
gals  and  possibly  immunotherapy  directed  at  the 
fungal  element  as  an  adjuvant  therapy.1516 

CONCLUSION 

Chronic  sinusitis  in  the  pediatric  population 
deserves  careful  consideration  by  the  treating 
physician.  The  disease's  impact  on  both  the  pa- 
tient and  the  patient's  family  is  often  underesti- 
mated. It  not  only  affects  the  child's  health  and 
quality  of  life  but  can  have  a stressful  financial 
impact  on  the  family  due  to  the  chronic  use  of 
multiple  medications  and  missed  days  of  work 
when  the  child  is  kept  out  of  school  and  daycare. 
Antibiotic  and  adjunctive  medical  therapy  re- 
mains the  mainstay  of  treatment,  but  attention 
must  be  given  to  all  exacerbating  conditions. 
With  proper  treatment  of  these  conditions  and 


J La  State  Med  Soc  VOL  152  October  2000  473 


involvement  of  the  family  in  the  long-term  man- 
agement, the  clinical  outcome  will  be  more  re- 
warding. 

REFERENCES 

1.  Clement  PAR,  Bluestone  CD,  Gordts  F,  et  al. 
Management  of  rhinosinusitis  in  children.  Arch 
Otolaryngol  1998;124:31-34. 

2.  Kaliner  MA,  Osguthorpe  JD,  Fireman  P,  et  al. 
Sinusitis:  bench  to  bedside.  J Allergy  Clin  Immunol 
Suppl  1997;99:3829-3847. 

3.  Lusk  P.  Pediatric  Sinusitis.  New  York:  Raven  Press; 
1992. 

4.  Parsons  DS.  Chronic  sinusitis.  Otolaryngol  Clin 
North  Am  1996;29:1-9. 

5.  Lesserson  JA,  Kieserman  SP,  Finn  DG.  The 
radiographic  incidence  of  chronic  sinus  disease  in 
the  pediatric  population.  Laryngoscope 
1994;104:159-166. 

6.  Rosenfield  RM.  Pilot  study  of  outcomes  in  pediatric 
rhinosinusitis.  Arch  Otolaryngol  1995;121:729-736. 

7.  Gungor  A,  Corey  JP.  Pediatric  sinusitis:  a literature 
review  with  emphasis  on  the  role  of  allergy. 
Otolaryngol  Head  Neck  Surg  1997;116:4-15. 

8.  Shapiro  GG,  Virant  FS,  Furukawa  CT,  et  al. 
Immunologic  defects  in  patients  with  refractory 
sinusitis.  Pediatrics  1991;87:311-316. 

9.  Barbero  GJ.  Gastroesophageal  reflux  and  upper 
airway  disease.  Otolaryngol  Clin  North  Am 
1996;29:27-37. 


10.  Bothwell  MP,  Parsons  DS,  Talbot  A,  et  al.  Outcome 
of  reflux  therapy  on  pediatric  chronic  sinusitis. 
Otolaryngol  Head  Neck  Surg  1999;121:255-262. 

11.  Milczuk  HA,  Dailey  RW,  Wessbacher  FW,  et  al. 
Nasal  and  paranasal  sinus  anomalies  in  children 
with  chronic  sinusitis.  Laryngoscope  1993;103:247- 
252. 

12.  Umetsu  DT,  Moss  RB,  Viong  W,  et  al.  Sinus  disease 
in  patients  with  severe  cystic  fibrosis:  relation  to 
pulmonary  exacerbation.  Lancet  1990;335:1077- 
1078. 

13.  Nishioka  GJ,  Barbero  GJ,  Vionig  P,  et  al.  Symptom 
outcome  after  functional  endoscopic  sinus  surgery 
in  patients  with  cystic  fibrosis:  a prospective  study. 
Otolaryngol  Head  Neck  Surg  1995;113:440-445. 

14.  April  MM.  Management  of  chronic  sinusitis  in 
children  with  cystic  fibrosis.  Pediatr  Pulmonol  Suppl 
1999;18:76-77. 

15.  Muntz  HR.  Allergic  fungal  sinusitis  in  children. 
Otolaryngol  Clin  North  Am  1996;29:185-191. 

16.  Mabry  RL,  Mabry  CS.  Allergic  fungal  sinusitis:  the 
role  of  immunotherapy.  Otolaryngol  Clin  North  Am 
2000;33:433-440. 


Dr  Lippincott  is  a resident , Department  of 
Otolaryngology  - Head  and  Neck  Surgery, 
Tulane  University  Health  Sciences  Center  in 
New  Orleans,  Louisiana. 

Dr  Brown  is  Assistant  Professor,  Department  of 
Otolaryngology  - Head  and  Neck  Surgery  and 
Assistant  Clinical  Professor,  Department  of  Pediatrics, 
Tulane  University  Health  Sciences  Center 
in  New  Orleans,  Louisiana. 


474  J La  State  Med  Soc  VOL  152  October  2000 


h 


A Groin  Mass 

Scott  Wilson,  MD;  Rod  Chandler,  MD;  and  Harold  R.  Neitzschman,  MD 


A 27-year-old  man  complained  of  a mass  in  his  left  groin  that  he  noticed  after  sustaining  a 
muscle  pull  during  a basketball  game. 


Figure  1.  AP  of  the  pelvis. 


Figure  3.  Axial  I.R.  of  the  left  groin. 


Figure  2.  Coronal  T1  of  the  left  groin. 


Figure  4.  Photograph  of  left  groin. 


What  is  your  diagnosis? 
Elucidation  is  on  page  476. 


J La  State  Med  Soc  VOL  152  October  2000  475 


Radiology  Case  of  the  Month 
Case  Presentation  is  on  page  473. 

RADIOLOGIC  DIAGNOSIS  - Adductor  muscle 
pseudotumor 

PATHOLOGIC  DIAGNOSIS  — Same 

INTERPRETATION  OF  IMAGING 

The  AP  of  the  pelvis  (Figure  1)  does  not  reveal 
any  changes.  Figures  2 and  3 demonstrate  a 
mass  in  the  left  groin  isointense  with  muscle. 
The  signal  characteristics  and  appearance  are 
indicative  of  a rupture  of  the  adductor  muscle 
and  changes  are  that  of  a pseudotumor.  The 
groin  mass  is  shown  in  Figure  4. 

DISCUSSION 

Total  rupture  of  an  adductor  muscle  can  present 
as  a soft  tissue  mass  in  the  medial  part  of  the 
proximal  thigh.  Adducting  the  thigh  against 
resistance  will  result  in  the  mass  becoming 
rounder  and  firmer.  The  mass  can  often  be 
confused  with  a femoral  hernia,  a femoral  artery 
aneurysm,  or  a soft  tissue  tumor,  in  particular 
an  intramuscular  lipoma,  which  will  demon- 
strate shape  and  consistency  changes  during 
muscle  contraction  similar  to  an  adductor 
muscle  rupture.1  Definitive  diagnosis  can  be 
made  with  MRI,  which  will  show  the  mass  to 
consist  of  normal  muscle  tissue.  A common 
cause  of  this  injury  is  the  kicking  motion 
demonstrated  by  many  soccer  players  in  which 
a strong  contraction  of  the  adductor  muscles 
occurs  with  the  leg  widely  abducted  and  the  hip 
flexed.2  However,  the  injury  may  occur  in  less 
stressful  situations.  Adductor  muscle  ruptures 
have  been  described  in  bowlers  and  in  patients 
who  did  not  remember  any  significant  trauma.3  4 
Cases  resulting  from  in-significant  trauma  will 
often  present  chronically  with  a history  of  a 
growing  mass.  The  growth  is  probably  due  to  a 
reactive  hypertrophy  that  occurs  after  the 
ruptured  muscle  heals  with  a more  proximal 
insertion  site.3 


Such  a presentation  is  important  because 
it  can  further  increase  suspicion  of  a soft  tissue 
tumor,  stressing  the  value  of  MRI  to  obviate 
the  need  for  a biopsy. 

REFERENCES 

1.  Kindblom  LG,  Angervall  L,  Stener  B,  et  al. 
Intermuscular  and  intramuscular  lipomas  and 
hibernomas.  A clincal,  roentgenologic,  histologic, 
and  prognostic  study  of  46  cases.  Cancer 
1974;33:754-762. 

2.  Symeonides  PR  Isolated  traumatic  rupture  of  the 
adductor  longus  muscle  of  the  high.  Clin  Orthop 
1972;88:64-66. 

3.  Peterson  L,  Stener  B.  Old  total  rupture  of  the 
adductor  longus  muscle.  A report  of  seven  cases. 
Acta  Orthop  Scand  1976;47:653-657. 

4.  Hoon  JR.  Adductor  muscle  injuries  in  bowlers. 
JAMA  1959;171:2087. 


Dr  Wilson  is  Assistant  Professor  of  Orthopedics  at 
Louisiana  State  University  Health  Sciences  Center, 

New  Orleans,  Louisiana. 

Dr  Chandler  is  a resident  in  Orthopedics  at 
Louisiana  State  University  Health  Sciences  Center, 

New  Orleans,  Louisiana. 

Dr  Neitzschman  is  a professor  of  Radiology  and 
Pediatrics  at  Tulane  Health  Sciences  Center, 
New  Orleans,  Louisiana. 


476  J La  State  Med  Soc  VOL  152  October  2000 





Walker  Percy’s  Magic  Mountain 


Laurel  A.  Saunders,  BA 


This  manuscript , written  by  Laurel  A.  Saunders , a 
second-year  medical  student  at  Tulane  University , was 
presented  at  the  annual  meeting  of  the  History  of 
Medicine  Society  and  received  an  Honorable  Mention. 
The  paper  summarizes  Walker  Percy's  medical  life  and 
his  fight  with  tuberculosis. 


Several  years  after  his  final  discharge  from 
a medical  therapeutic  system  shut  down 
because  of  its  ineffectiveness.  Walker 
Percy  began  writing  a novel  that  was  never  pub- 
lished. Some  of  those  who  read  this  failed  tran- 
script entitled  The  Gramercy  Winner , deemed  it 
only  an  American  version  of  the  previously  writ- 
ten and  successful  novel  by  Thomas  Mann,  The 
Magic  Mountain.  If  one  did  not  know  that  The 
Gramercy  Winner  was  a self-conscious  account  of 
a young  man  recuperating  from  tuberculosis  in 
an  Adirondack  Village  in  1941,  one  could  dis- 
miss the  rejected  novel  as  merely  a burgeoning 
author's  attempt  at  fiction.  What  makes  this  set- 
back deserving  of  a more  thoughtful  pause,  how- 
ever, is  to  consider  it  as  one  of  the  first  pieces  of 
evidence  that  a physician  left  medicine  to  become 
a serious  writer.  It  was  during  the  isolation  and 


retreat  forced  upon  him  by  the  conventional 
treatment  of  tuberculosis  during  the  1940s  that 
Walker  Percy  began  his  break  from  medicine. 
What  follows  is  an  account  of  Percy's  treatment 
as  a vehicle  to  study  the  methods  of  diagnosis 
and  therapy  of  tuberculosis  during  the  1940s  and 
to  address  some  of  the  reasons  why,  after  the 
course  of  his  therapy,  he  eventually  said,  "TB 
liberated  me."1 

WALKER  PERCY’S  MAGIC  MOUNTAIN 

After  placing  first  in  a competitive  examination 
for  Columbia's  College  of  Physicians  and  Sur- 
geons division  at  Bellevue  Hospital  in  New  York 
City,  Walker  Percy  began  a pathology  internship 
in  January  1942.2  He  and  his  eleven  fellow  pa- 
thology interns  fell  under  the  watchful  and  de- 
manding eye  of  Dr  von  Glahn.  In  exchange  for  a 
modest  salary  as  well  as  room  and  board,  Percy 
was  charged  with  meeting  the  house-staff  team 
every  morning  to  see  and  discuss  the  progress 
of  each  patient,  work  in  the  outpatient  clinic  for 
a few  hours  every  afternoon,  and  in  the  evening 
work  up  new  patients,  perform  laboratory  work, 
and  write  summaries  of  the  morning  rounds.  But 


J La  State  Med  Soc  VOL  152  October  2000  477 


perhaps  the  duty  that  had  the  most  profound 
impact  on  Percy's  life  was  the  numerous  autop- 
sies he  performed  in  the  basement  morgue  of 
Bellevue  (125  autopsies  within  the  span  of  only 
a few  months).  Most  of  the  cadavers  worked  on 
at  Bellevue  were  known  as  "five-day  cases," 
which  were  bodies  unclaimed  after  five  days, 
or  "murders  and  floaters,"  that  is,  bodies  pulled 
out  of  the  East  River.3  While  Percy  assumed  it 
was  the  long  hours  he  kept  which  made  him 
tired  and  prone  to  illness,  a routine  chest  x-ray 
pointed  to  a different  source  of  his  symptoms. 

The  x-ray  revealed  a small,  quarter-sized  le- 
sion in  the  second  intercostal  space  of  Percy's 
right  lung.  This  finding,  along  with  a non-pro- 
ductive cough,  frequent  head  colds,  sore  throat, 
loss  of  strength,  and  slight  fatigue  plaguing  him 
since  March,  made  Percy  fear  that  he  had  con- 
tracted tuberculosis.  Percy  did  not  feel  gener- 
ally ill  and  did  not  have  weight  loss,  hemopty- 
sis, night  sweats,  loss  of  appetite,  or  chest  pain, 
although  he  did  have  an  elevated  temperature 
that  fluctuated  between  99  and  100  degrees  Fahr- 
enheit. The  exact  source  of  infection  remains 
unclear,  although  Percy  himself  believed  he  con- 
tracted tuberculosis  from  one  of  the  autopsies 
he  performed.  Even  though  Dr  von  Glahn 
prided  himself  on  running  an  orderly  program, 
insisting  that  all  of  his  interns  constantly  wash 
during  their  procedures,  he  had  to  face  the  fact 
that  four  of  his  twelve  interns  contracted  tuber- 
culosis that  year;  twice  the  usual  incidence.4 
Percy  admitted  that  he  and  his  fellow  interns 
were  careless  at  times,  often  not  protecting  them- 
selves with  gloves  or  masks  during  procedures. 
Other  possible  sources  of  transmission  could  be 
from  one  of  Percy's  live  patients  (Bellevue  served 
a large  portion  of  immigrant  poor  in  the  Lower 
East  Side  which  had  a high  incidence  of  tuber- 
culosis) or  from  Percy's  Aunt,  Anne  Barrett,  who 
had  died  of  tuberculosis  in  1936  with  whom 
Percy  had  contact  as  a young  child.3 

Regardless  of  the  source  of  transmission,  the 
discovery  of  the  lesion  on  the  x-ray  film  marked 
the  beginning  of  Percy's  transition  from  the  ob- 
server to  the  subject  of  study.  Upon  this  realiza- 
tion Percy,  reflected  that  the  "same  scarlet  tu- 


bercle bacillus  I used  to  see  lying  crisscrossed 
like  Chinese  characters  in  the  sputum  and  lym- 
phoid tissue  of  the  patients  at  Bellevue  [was  no 
longer]  out  there  . . . now  I was  one  of  them."5 
To  begin  his  course  of  medical  care,  Percy  was 
whisked  away  from  the  morgue  to  a small  pri- 
vate room  overlooking  the  East  River  in  the  TB 
service  of  Dr  J.  Burns  Amberson.  Dr  Amberson 
was  part  of  a distinguished  team  that  included 
Dr  Andre  Cournand  and  Dr  Dickinson  W. 
Richards  (later,  Drs  Cournand  and  Richards 
were  to  win  the  Nobel  Prize  in  Medicine  in  1956 
for  their  work  with  the  Forssmann's  heart  cath- 
eter).3 

By  the  time  Dr  Amberson  took  on  Walker 
Percy  as  a patient  in  1942,  five  major  discover- 
ies had  been  made  to  alter  the  medical  history 
of  tuberculosis.  The  first  advance  came  in  1761 
with  Leopold  Auenbrugger's  New  Invention  to 
Detect  by  Percussion  Hidden  Diseases  in  the 
Chest,  the  culmination  of  7 years  of  testing  his 
patient's  lungs  with  experimental  drumming.6 
Auenbrugger's  method  of  percussion  to  com- 
pare different  densities  of  the  lung  was  adapted 
from  a technique  used  by  his  father,  a tavern 
keeper,  to  judge  the  amount  of  wine  left  in  his 
casks  by  the  way  they  sounded  when  he  tapped 
on  them.  The  second  discovery  was  Rene 
Theophile  Laennec's  stethoscope,  described  in 
his  book  The  Diagnostic  Value  of  Mediate  Auscul- 
tation by  Use  of  a Stethoscope , published  in  1819. 7 
While  conducting  his  research,  which  included 
extensive  descriptions  on  rales  and  rhonchi, 
Laennec  himself  was  an  incurable  consumptive 
and  died  in  1826.  The  third  and  fourth  discover- 
ies were  both  made  by  Robert  Koch.  In  1882, 
Koch  named  the  microbe  he  found  in  the  spu- 
tum of  consumptive  patients  while  at  the  Impe- 
rial Health  Institute  in  Berlin,  "the  tubercle  ba- 
cillus". Eight  years  after  Koch  discovered  the 
tubercle  bacillus,  he  presented  the  world  with 
tuberculin  as  a cure  for  the  disease.  His  claims 
were  disproved  however,  and  his  career  dam- 
aged after  his  product  proved  to  be  harmful  to 
many  patients.  Despite  this  setback,  tuberculin 
was  soon  adapted  as  a useful  skin  test  to  detect 
infected  individuals.  A man  named  Wilhelm 


478  J La  State  Med  Soc  VOL  152  October  2000 


Roentgen  in  1895  created  the  fifth  landmark  in 
the  medical  history  of  tuberculosis.  In  his  paper 
entitled  On  A New  Kind  of  Rays , Roentgen  pre- 
sented the  application  of  x-rays  in  medical  prac- 
tice that  allowed  the  physician  access  to  the  " in- 
ner man."8 

From  the  base  created  by  these  five  medical 
discoveries  and  the  refinements  made  upon 
them,  one  can  fairly  conclude  that  early  and  ac- 
curate pulmonary  diagnosis  was  a compara- 
tively recent  addition  to  medicine  by  the  time 
Dr  Amberson  began  working  with  Walker  Percy. 
What  lagged  behind  these  advancing  efforts  in 
diagnosis  were  more  efficacious  therapies  for 
tuberculosis.  Perhaps  the  delay  in  lasting  treat- 
ment was  due  in  part  to  the  stigma  still  attached 
to  the  disease.  Despite  the  knowledge  that  tu- 
berculosis was  an  infectious  disease  since  Koch's 
discovery  in  1882,  popularly  held  beliefs  that 
consumption  was  somehow  a physical  manifes- 
tation of  an  internal  weakness  were  still  preva- 
lent in  1942.4D.H.  Lawrence,  born  shortly  after 
Koch's  discovery,  was  himself  a tuberculosis 
patient.  Lawrence  eloquently  captured  the  idea 
that  the  disease  was  somehow  connected  to  the 
character  of  the  sufferer  in  his  poem  "Healing" 
when  he  writes:  "I  am  not  a mechanism,  an  as- 
sembly of  various  sections.  / And  it  is  not  be- 
cause the  mechanism  is  working  wrongly,  that  I 
am  ill.  / I am  ill  because  of  wounds  to  the  soul, 
to  the  deep  emotional  self."9  Indeed,  rest,  peace- 
ful surroundings,  and  a positive  attitude  were 
thought  to  be  the  best  cure,  which  is  one  of  the 
reasons  why  sanatoria  became  such  a popular 
method  of  treatment  (the  1942  Sanatorium  Di- 
rectory listed  699  institutions  caring  for  tuber- 
culosis patients  with  97,726  beds).7 

With  the  help  of  Dr  Amberson,  Percy  began 
making  arrangements  to  leave  for  the  Trudeau 
Sanatorium  after  resigning  from  the  Bellevue 
staff  on  June  4, 1942.  There  was  a strong  connec- 
tion between  the  Trudeau  Sanatorium  and 
Bellevue  Hospital  as  demonstrated  by  Bellevue 
always  having  a number  of  places  reserved  there 
for  the  treatment  of  its  staff.  Not  only  did  Dr 
Amberson  have  close  professional  and  personal 
ties  to  Trudeau,  including  his  sister  who  was  a 


nurse  there,  but  James  Alexander,  the  president 
of  Trudeau,  was  a graduate  of  P & S and  also  the 
founder  of  the  Bellevue  tuberculosis  service  in 
1903. 3 While  the  mental  and  physical  rest  sana- 
toria provided  was  considered  the  keystone 
upon  which  recovery  was  built,  Percy  under- 
went an  artificial  pneumothorax  on  his  right 
lung  in  July  1942  while  still  at  Bellevue;  a surgi- 
cal procedure  considered  to  be  a promoter  of  the 
healing  process. 

The  artificial  pneumothorax  was  just  one  part 
of  a triad  that  made  up  the  broader  category  of 
collapse  therapy.  The  other  two  components  were 
phrenic  paralysis  and  extrapleural  thoracoplasty. 
Briefly,  the  phrenic  paralysis  was  thought  of  as 
minor  collapse  therapy  because  it  didn't  compress 
the  lung  and  only  produced  a moderate  amount 
of  relaxation  of  the  diaphragm.  It  was  considered 
valuable  in  cases  with  small  or  no  cavitary  lesions 
and  without  widespread  fibrous  disease.  Extra- 
pleural thoracoplasty,  the  resection  of  ribs  to  re- 
duce the  size  of  the  pleural  space,  was  a perma- 
nent method  of  treatment  reserved  for  the  ulcer- 
ative, cavitary,  destructive  cases.  In  fact,  thoraco- 
plasty was  preferred  by  some  physicians  over 
pneumothorax  for  any  individual  greater  than 
thirty-five  years  of  age  presenting  with  a fibrotic, 
cavernous  lesion  in  need  of  a permanent  mea- 
sure of  treatment,  producing  a satisfactory  con- 
trol of  the  disease  in  75%  to  90%  of  patients.10,11 

The  indications  for  the  popular  artificial 
pneumothorax  were  still  quite  complicated  by 
the  time  Percy  had  his  operation  in  1942,  but 
some  guiding  principles  were  nonetheless  firmly 
in  place  regarding  the  general  description  of  the 
lesion  and  the  condition  and  age  of  the  patient 
for  whom  it  was  being  considered.  Artificial 
pneumothorax  (AP)  was  indicated  in  fibrocas- 
eous,  ulcerative,  and  cavernous  lesions.  It  was 
considered  useless  in  encapsulated  tuberculo- 
mas and  in  miliary  disseminations.  The  proce- 
dure was  contraindicated  when  dealing  with 
pneumonic  consolidations  that  did  not  collapse 
in  the  first  place  and  which  were  often  compli- 
cated by  rupture  of  the  pleura  with  resultant 
empyemas.10  Clinical  considerations  dictated 
that  an  AP  was  not  initiated  during  acute  phases 


J La  State  Med  Soc  VOL  152  October  2000  479 


of  tuberculosis  unless  forced  to  take  action  by 
the  occurrence  of  severe  hempotysis.  Ideally,  the 
patient  was  a young  adult  but  a surgeon  would 
operate  on  a person  less  than  fifty  years  of  age, 
or  fifty-five  at  the  very  most.  Other  contrain- 
dications included  patients  with  concurrent 
asthma,  emphysema,  silicosis,  definite  myocar- 
dial damage,  and  those  with  tuberculosis  of  the 
bronchi.  Complications  of  AP  included  pleural 
effusion,  tuberculous  empyemas,  mixed  empy- 
emas, spontaneous  pneumothoraces,  air  embo- 
lism, pleural  shocks  or  pleural  reflexes,  medias- 
tinal hernias,  and  pneumoperitoneum.  T.N. 
Rafferty,  MD,  in  his  book  Artificial  Pneumotho- 
rax in  Pulmonary  Tuberculosis  published  in  1944, 
summarized  the  reports  of  several  leading  re- 
searchers of  the  day  that  showed  that  of  the 
18,636  cases,  34.3  percent  were  dead,  33.7  per- 
cent were  considered  not  cured,  and  32  percent 
were  considered  cured.11  These  dismal  results 
reveal  that  pneumothorax,  and  indeed  all  of  col- 
lapse therapy,  was  far  from  seen  as  a cure  for 
tuberculosis.  Instead,  optimal  treatment  was 
considered  to  be  a combination  of  some  kind  of 
collapse  therapy  along  with  sanatorial  care. 

With  the  first  part  of  his  treatment  regimen 
completed  at  Bellevue,  Percy  departed  for 
Saranac  Lake  to  begin  the  second  part  at  the 
Trudeau  Sanatorium  toward  the  end  of  August. 
Another  tuberculous  patient  heading  for 
Trudeau  that  year  of  interest  was  "Laughing 
Larry"  Doyle  of  the  New  York  Giants  (the  first 
player  to  hit  a home  run  out  of  the  Polo  Grounds) 
whose  teammate,  Christy  Mathewson,  had 
made  the  same  journey  a few  years  before.  Years 
earlier,  in  1887,  Robert  Louis  Stevenson  became 
a Trudeau  patient  and  wrote  a series  of  essays 
about  the  experience  for  Scribner's  magazine. 
Founding  arguably  the  most  well-known  sana- 
torium in  the  United  States,  Edward  Livingston 
Trudeau  was  a kind  of  celebrity  himself. 

Trudeau  was  practicing  medicine  in  New 
York  City  when  he  developed  a cough  and  was 
diagnosed  with  tuberculosis  with  no  more  than 
one  year  to  live  by  Edward  C.  Janeway  in  1872. 
A sportsman  and  hunter,  Trudeau  decided  to  live 
out  his  last  days  doing  what  he  loved  in  the  beau- 


tiful Adirondacks.  To  everyone's  surprise  he  re- 
gained his  health  and  by  1884  opened  "The  Little 
Red  Cabin",  a sanatorium  built  on  the  same  prin- 
ciples he  read  about  guiding  the  treatment  of 
pulmonary  tuberculosis  in  Germany  by  Herman 
Brehmer  and  Peter  Dettweiler.  The  essential 
therapeutic  elements  were  life  in  the  open  air, 
an  ample  diet,  rest,  and  moderate  exercise.  For 
Percy  and  his  fellow  patients,  this  meant  adher- 
ing to  a fairly  rigid  schedule.  They  would  typi- 
cally rise  at  7:00  am  and  eat  a hearty  breakfast. 
Diets  were  usually  generous  and  varied  but  with 
an  emphasis  on  milk  and  eggs,  the  latter  most 
often  eaten  raw.  One  1906  study  showed  that 
caloric  intake  ranged  from  2,140  to  4,380  calo- 
ries daily  at  various  American  sanatoriums.12 
After  breakfast,  they  would  spend  two  hours 
resting.  Lunch  was  followed  by  another  rest  pe- 
riod and  then  a long  stretch  of  free  time.  Patients 
were  expected  to  spend  between  seven  and  ten 
hours  outside  daily,  so  "free  time"  could  be  spent 
strolling  into  town  or  perhaps  reading  a book 
borrowed  from  the  extensive  Mellon  Memorial 
Library.  Everyone  was  expected  to  be  back  on 
the  grounds  by  7:00  pm,  in  their  cottages  by  9:00 
pm  and  with  their  lights  out  by  10:00  pm.  Ev- 
eryone was  required  to  report  to  the  exercise 
clinic  that  was  held  in  the  Medical  building  once 
every  two  weeks,  bringing  with  them  their  daily 
record  sheets.  At  no  time  was  one  allowed  to 
consume  alcohol  but  one  was  able  to  smoke. 

The  rules  and  regulations  at  the  San  were 
supplemented  by  some  of  Trudeau's  other  phi- 
losophies as  well.  Williams  writes  that  "Edward 
Livingstone  Trudeau  taught  that  the  key  to  over- 
coming this  illness  was  acquiescence;  learn  to 
live  within  one's  limitations;  make  the  best  of 
what  was  available."  This  meant  that  the  patient 
was  encouraged  to  discover  new  talents  in  him- 
self in  order  to  adjust  more  easily  to  a life  with 
tuberculosis.  Williams  continues  to  say  that  the 
Trudeau  philosophy  even  suggested  that  the 
patient  learn  a new  craft  or  a new  profession.  One 
can  well  imagine  Walker  Percy  in  this  environ- 
ment of  personal  renewal  and  professional 
reconfiguration.  He  had  begun  reading  books 
to  pass  the  time  during  the  early  course  of  his 


480  J La  State  Med  Soc  VOL  152  October  2000 


treatment  at  Bellevue,  in  particular  works  by 
Dostoyevsky  and  Thomas  Mann's  Magic  Moun- 
tain. Now  at  the  sanatorium,  he  had  even  more 
time  on  his  hands  which  he  used  to  study  the 
writings  of  Kierkegaard,  Heidegger,  Sarte, 
Tolstoy,  Kafka,  and  Camus.3  Percy  revealed  what 
these  writers  meant  to  him  when  he  said,  "The 
effect  was  rather  a shift  of  ground,  a broadening 
of  perspective,  a change  of  focus."3  It  was  the 
first  opportunity  since  entering  medical  school 
that  he  had  the  time  to  consider  theories  and 
ideas  that  were  not  directly  related  to  medicine 
and  they  were  opening  up  new  possibilities  for 
him. 

But  Percy  was  not  going  to  abandon  the  idea 
of  a medical  practice  so  easily.  In  fact,  upon  his 
discharge  from  Trudeau  in  September  1944,  he 
taught  Pathology  to  second-year  medical  school 
students  at  Columbia.  Unfortunately,  however, 
Percy  had  a relapse  and  was  forced  to  seek 
sanatorial  treatment  once  again  in  May  1945,  this 
time  at  Gaylord  Sanatorium  in  Wallingford,  Con- 
necticut.4 The  treatment  at  Gaylord  was  not  un- 
like that  at  Trudeau.  In  fact  the  director.  Dr 
Russell  Lyman,  was  once  a patient  and  employee 
of  Trudeau.  Although  the  treatment  regimen  was 
familiar  to  him,  Percy's  focus  was  a new  one. 
Tolson  explains  that  Percy  "had  been  reading 
widely  before  he  came  to  Gaylord,  but  now  his 
reading  became  more  pointed,  more  directed. 
He  read  like  a person  who  was  trying  to  define 
his  subject.4" 

After  discharge  from  Gaylord  on  August  23, 
1945  with  a diagnosis  of  quiescent  tuberculosis, 
Percy  never  returned  to  medicine.  In  between 
the  time  he  was  diagnosed  by  Dr  Amberson  in 
the  Spring  of  1942  while  at  Bellevue  to  his  final 
discharge  from  the  sanatorial  system.  Walker 
Percy  made  the  transition  from  physician  to 
writer.  While  reflecting  on  his  time  at  Trudeau, 
Percy  explained: 

I began  to  question  everything  I had  once 

believed. . . I never  turned  my  back 

on  science.  It  would  be  a mistake  to  do  so 

- throw  out  the  baby  with  the  bath 


water.  I wanted  to  find  answers  through 
an  application  of  the  scientific  method  . . . 

But  I gradually  began  to  realize  that  as  a 
scientist — a doctor,  a pathologist — I 
knew  so  very  much  about  man,  but  had 
little  idea  what  man  is."13 

CONCLUSION 

During  the  process  of  treatment,  Percy  realized 
what  he  wanted  to  take  away  from  medicine  was 
its  analytical  thought  process  and  apply  it  to  a 
study  of  man  through  writing.  Perhaps  it  was 
some  combination  of  the  books  he  read,  the  phi- 
losophy espoused  at  Trudeau,  and  the  confron- 
tation with  his  own  mortality  that  made  him 
begin  to  rethink  the  direction  of  his  life.  What  is 
clear,  however,  is  that  Walker  Percy  went  on  to 
have  an  accomplished  career  as  a writer,  which 
included  winning  a National  Book  Award  for 
fiction  in  1962  for  his  novel  The  Moviegoer. 
Through  study  of  what  Percy's  life  with  tuber- 
culosis was  like  in  the  1940s  and  appreciating 
his  successful  work  as  an  author,  maybe  one  can 
have  a greater  understanding  of  what  Percy 
meant  when  he  said  "TB  liberated  me."1 

REFERENCES 

1.  Cremeens  C.  Walker  Percy:  The  Man  and  the 
Novelist.  In:  Lawson  LA,  Karamer  V (editors). 
Conversations  with  Walker  Percy.  Jackson,  Miss: 
University  Press  of  Mississippi;  1985:34. 

2.  "Author's  Questionnaire"  for  Alfred  A.  Knoff. 
September  16,  1960. 

3.  Samway  SJ,  Patrick  H.  Walker  Percy:  A Life.  New 
York:  Farrar,  Strauss  and  Giroux;  1997. 

4.  Tolson  Jay.  Pilgrim  in  the  Ruins:  A Life  of  Walker  Percy. 
New  York:  Simon  and  Schuster;  1992. 

5.  Percy  Walker.  From  Facts  to  Fiction  Book  Week 
December  25,  1966:  5,  9. 

6.  Bettmann  OL.  A Pictorial  History  of  Medicine. 
Springfield:  Charles  C.  Thomas;  1956. 

7.  Chadwick  HD,  Pope  AS.  The  Modern  Attack  on 
Tuberculosis,  revised  edition.  New  York:  The 
Commonwealth  Fund;  1946. 

8.  Williams  Harley.  Requiem  for  a Great  Killer.  London: 
Health  Horizon  Limited;  1973. 

9.  Lawrence  DH.  D.  H.  Lawrence  Selected  Poems.  New 
York:  The  Viking  Press;  1959. 


J La  State  Med  Soc  VOL  152  October  2000  481 


10.  Stone  MJ,  Dufault  P.  The  Diagnosis  and  Treatment  of 
Pulmonary  Tuberculosis.  Philadelphia:  Lea  and 
Febiger;  1946. 

11.  Rafferty  TN.  Artificial  Pneumothorax  in  Pulmonary 
Tuberculosis.  New  York:  Grune  and  Stratton;  1944. 

12.  Teller  ME.  The  Tuberculosis  Movement.  Westport: 
Greenwood  Press;  1988. 

13.  Coles  R.  Walker  Percy:  An  American  Search.  Boston: 
Little  Brown;  1978. 


Ms  Saunders  is  a second-year  medical  student  at 
Tulane  University  Health  Sciences  Center 
in  New  Orleans , Louisiana. 


The  author  and  the  Journal  welcome  comments  on 
the  history  of  medicine. 


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482  J La  State  Med  Soc  VOL  152  October  2000 


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Adolescent  Violence 


H.  Jay  Collinsworth,  MD 


The  1997  juvenile  violent  crime  arrest  rate 
in  Louisiana  was  506/100,000  youths 
aged  10  to  17.  This  compared  to  a national 
average  of  412/100,000.  Once  again,  Louisiana 
lags  behind  its  sister  states.  The  1990-1997  teen 
death  rate  from  accident,  homicide,  and  suicide 
ranked  Louisiana  47th  out  of  the  50  states.1  A 
1997  study  by  the  US  Department  of  Education 
found  that  1 in  10  schools  reported  serious  vio- 
lent crimes  in  the  1996-1997  school  year.2  Last 
year  the  mass  media  accounts  of  school 
shootings  in  Louisiana,  Arkansas,  Kentucky,  and 
Colorado  created  what  appeared  to  be  an  almost 
daily  litany  of  violence  and  tragedy  at  our 
schools.  With  such  grim  statistics  in  mind,  the 
Louisiana  State  Medical  Society  approved  a 1999 
House  of  Delegates  resolution  authorizing  the 
Society's  Committee  on  Public  Health  to  orga- 
nize an  ad  hoc  committee  to  review  this  alarm- 
ing trend  of  increasing  violence  among  our 
youth.  The  committee  invited  guests  from  the 
Louisiana  Attorney  General's  Office,  the  Loui- 
siana Community  Policing  Institute,  the  Louisi- 
ana Youth  Challenge  National  Guard,  the  Loui- 


siana chapter  of  Students  Against  Destructive 
Decisions,  and  the  Northeast  Louisiana  Univer- 
sity School  of  Social  Work.  Each  of  these  repre- 
sentatives encouraged  physicians  of  all  special- 
ties to  inform  themselves  of  the  multiplicity  of 
causes  and  the  devastating  effects  of  the  epi- 
demic of  violence  among  our  youth.  Accord- 
ingly, this  issue  of  the  Journal  is  dedicated  to 
alerting  physicians  to  the  pervasive  nature  of 
adolescent  violence  and  its  many  underlying 
causes.  With  this  understanding  in  mind,  the 
clinical  steps  of  prevention  and  treatment  are 
discussed. 

Much  of  the  media  coverage  of  violence 
among  our  youth  focuses  on  the  teenager  as  the 
perpetrator  of  violent,  often  deadly,  acts  against 
fellow  youth.  Often  this  portrayal  neglects  the 
fact  that  children  are  both  direct  and  indirect 
victims  of  violence  from  both  their  peers  and 
their  community.  In  one  of  this  issue's  articles, 
"The  Effects  of  Community  Violence  Exposure 
on  Louisiana's  Children",  the  concept  of  com- 
munity violence  encompasses  not  only  the  di- 
rect acts  of  violence  but  also  the  witnessing  by 


J La  State  Med  Soc  VOL  152  October  2000  483 


Adolescent  Violence 


children  of  the  violent  acts  of  others.  A survey 
mentioned  in  the  article  describes  a neighbor- 
hood in  New  Orleans  where  91%  of  the  children 
have  been  witnesses  to  some  form  of  violence  in 
their  immediate  environment.  As  physicians,  we 
must  be  aware  that  young  children  are  particu- 
larly susceptible  to  the  effects  of  violence  even 
when  they  are  not  directly  the  victims  of  the  vio- 
lent act.  Of  particular  note,  community  violence 
is  a cumulative  risk  factor  for  a number  of  men- 
tal disorders  including  depressive,  anxiety,  con- 
duct, and  phobic  disorders. 

In  this  issue's  "Children,  Adolescents,  and 
Guns:  A Thought  Experiment",  the  role  of  fire- 
arms is  discussed  in  a manner  that  separates  the 
availability  of  firearms  from  the  rhetoric  on  gun 
control  and  into  the  realm  of  injury  prevention. 
Nationally,  firearm  injuries  are  the  second  lead- 
ing cause  of  death  in  persons  aged  10  to  24  years. 
Every  2 hours  an  American  child  dies  from  a 
gunshot.  Every  6 hours  a child  between  the  ages 
of  10  and  19  commits  suicide  with  a handgun. 
The  presence  of  a gun  in  the  home  statistically 
increases  the  likelihood  of  homicide  in  that  home 
almost  threefold.2  In  the  same  circumstance,  the 
possibility  of  suicide  increases  almost  fivefold.2 
In  Louisiana,  more  children  survive  their  gun- 
shot wounds  and  live  with  permanent  disabili- 
ties. The  total  costs  to  both  victim  and  society 
are  enormous.  The  paper  "Children,  Adoles- 
cents, and  Guns:  A Thought  Experiment"  pre- 
sents a model  for  firearm  injury  prevention  that 
can  define  a physician's  role  in  reducing  the 
number  of  intentional  and  nonintentional  fire- 
arm injuries,  disabilities,  and  deaths. 

As  clinicians  we  realize  that  every  disease 
has  a list  of  factors  that  contribute  to  the  scope 
of  that  disease.  Violence  is  no  exception.  Pov- 
erty, substance  abuse  and  its  inherent  criminal 
activity,  ready  availability  of  guns,  and  media 
exposure  to  violence  are  all  known  to  be  con- 
tributing factors  to  teen  violence  and  aggression. 
Lack  of  educational  and  employment  opportu- 
nities generate  a feeling  of  hopelessness  that  may 
also  act  as  a catalyst  for  violent  behavior.  In  this 
respect,  Louisiana  faces  another  grim  reality  in 


that  13%  of  our  teenagers  ages  16  to  19  are  not 
attending  school  or  working.  Thirty  percent  of 
our  children  live  in  poverty.  Both  of  these  statis- 
tics rank  Louisiana  48th  out  of  the  50  states.1  The 
article  "A  Developmental  Psychopathology  Ap- 
proach to  Understanding  and  Preventing  Youth 
Violence"  conceptualizes  violent  behavior  as  a 
developmental  outcome  that  can  result  from 
many  different  pathways  with  distinctly  causal 
processes.  This  framework  has  already  helped 
guide  some  of  the  more  effective  prevention  and 
treatment  strategies. 

"Violence  Prevention:  Myth  or  Reality"  re- 
views the  current  reality  of  violence  as  an  ev- 
eryday occurrence  in  our  schools,  workplaces, 
and  streets.  With  such  an  environment,  can  we 
as  adults  provide  a safe  environment  in  which 
our  children  can  master  the  interactive  skills 
necessary  to  become  a productive,  nonviolent 
member  of  society? 

On  behalf  of  the  LSMS  Committee  on  Pedi- 
atric Health,  I would  like  to  extend  sincere 
thanks  to  the  contributors  and  the  editorial  staff 
of  the  Journal  for  their  work  creating  this  issue 
on  "Adolescent  Violence."  We  hope  that  it  will 
be  of  timely  interest  to  the  medical  community. 

REFERENCES 

1.  The  Annie  Casey  Foundation.  KIDS  COUNT  2000. 
USA;  2000. 

2.  American  Academy  of  Pediatrics.  Child  Health  Issues: 
Youth  Violence.  Washington,  DC:  AAP  Washington 
Office;  December  1998. 


Dr.  Collinsworth  is  a pediatric  specialist  at 
Our  Lady  of  the  Lake  Regional  Medical  Center 
in  Baton  Rouge,  Louisiana  and  serves  as  the 
current  chair  of  the  Louisiana  State  Medical  Society 
Committee  on  Pediatric  Health.. 


484  J La  State  Med  Soc  VOL  152  October  2000 


Adolescent  Violence 


Proven  Practices  for  Reducing 
Aggressive  and  Noncompliant  Behaviors 
Exhibited  by  Young  Children 
at  Home  and  at  School 

Amanda  Vanderheyden,  MA  and  Joseph  C.  Witt,  PhD 


One  of  the  single  most  powerful  predictors  of  aggressive  and  noncompliant  behaviors  exhib- 
ited in  early  childhood  is  coercive  parent-child  interaction.  Coercive  parent-child  interaction 
has  been  linked  to  multiple  negative  outcomes  in  the  lives  of  children.  When  children  learn 
to  relate  to  their  parents  and  the  world  in  the  context  of  coercive  interaction,  they  are  likely  to 
experience  significant  deficits  in  the  prosocial  skills  critical  to  school  success.  These  children 
are  much  more  likely  to  experience  school  failure  and  teacher  and  peer  rejection.  Further, 
when  noncompliant  and  aggressive  children  enter  school,  they  are  most  frequently  exposed 
to  a series  of  ineffective  and  increasingly  restrictive  treatments.  Proven  strategies  exist  to 
teach  parents  and  children  prosocial  ways  of  interacting  and  to  address  these  problems  in  the 
classroom,  but  in  many  cases  these  types  of  services  are  not  easily  accessible  or  routinely 
available.  This  paper  makes  recommendations  for  identifying  effective,  proven  treatment 
strategies  when  practitioners  observe  coercive  parent-child  interaction  or  child  noncompli- 
ance and  aggression. 


C onsider  the  following.  A mother  sits  in  a 
waiting  room  at  a doctor's  office.  She  has 
two  young  children  with  her.  One  is  sit- 
ting on  her  lap.  The  older  child  is  walking  around 
the  room.  The  mother  appears  tired.  The  young 
child  on  her  lap  tugs  at  her  arm  wanting  her  at- 
tention. She  is  distracted.  She  tells  the  toddler 
moving  about  the  room,  "Don't  touch  that,  it 
might  break."  The  toddler  continues  exploring. 
She  becomes  irritated  and  says,  "If  you  come  sit 
down.  I'll  take  you  to  McDonald's  when  we 
leave."  The  toddler  continues  exploring.  She  says. 


"You  are  going  to  get  a spanking  when  we  get 
home  if  you  don't  come  here  now."  The  toddler 
has  found  a magazine  on  the  table  and  starts  to 
carry  it  back  to  his  mother.  The  baby  on  the 
mother's  lap  is  beginning  to  cry.  She  gets  off  her 
chair,  approaches  the  child  and  tells  him  to  put  the 
magazine  back  on  the  table.  Now,  the  toddler  be- 
gins to  cry,  too.  She  reaches  to  take  it  out  of  his 
hand,  and  he  yells,  "No!"  The  mother,  clearly  frus- 
trated and  overwhelmed,  stands  there  trying  to 
make  him  mind.  She  cajoles,  she  pleads,  she  threat- 
ens. As  she  grabs  for  the  magazine,  he  flops  onto 


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Adolescent  Violence 


the  floor  crying  and  kicking  his  legs.  The  mother, 
reaching  her  limit,  picks  him  up  in  her  left  hand, 
carries  him  back  to  the  chair,  and  spanks  him  on 
the  bottom.  This  time  when  the  child  returns  to 
the  magazine  still  crying  loudly,  the  mother  does 
not  intervene. 

This  interaction  is  very  common.  In  some  fami- 
lies these  series  of  events  may  be  repeated  hun- 
dreds of  times  per  day.  Without  intervention,  this 
type  of  interaction,  called  coercion,  is  highly  re- 
lated to  the  development  of  child  antisocial  be- 
havior. Reversing  this  pattern  of  parent-child  in- 
teraction is  necessary  to  the  development  of 
prosocial  skills  critical  to  the  child's  success  at 
home,  in  school,  and  in  the  larger  community. 

Consider  again  the  above  scenario.  This  time 
the  mother  arrives  at  the  doctor's  office  with  the 
younger  child  in  a fold-up  stroller.  She  has  a bag 
of  small  toys,  juice,  and  a snack.  As  she  enters  the 
office  she  is  talking  with  the  child  about  their  ride 
on  the  bus.  She  holds  the  child's  hand  as  they  stand 
at  the  office  door  and  tells  him,  "Let's  find  a good 
place  to  sit."  When  seated,  the  mother  tells  the 
child,  "I  will  check  us  in,  would  you  like  your  col- 
oring book  or  blocks?"  After  obtaining  the  paper 
work,  she  returns  to  her  seat.  She  engages  both  of 
the  children  in  conversation.  When  the  toddler 
says,  "Car!"  She  says,  "Yes,  that  is  a picture  of  a 
red  car.  Do  you  like  to  ride  in  cars?"  She  explains 
to  both  children  quietly  what  events  will  take  place 
in  the  next  hour.  She  offers  juice  and  snacks  after 
some  time  has  passed.  When  the  toddler  becomes 
fussy,  she  prompts  him  to  "use  his  words"  and 
indicates  her  understanding  that  it  is  difficult  to 
wait,  then  redirects  him  to  a new  activity.  If  he  were 
to  approach  an  item  in  the  room  that  is  dangerous 
(eg,  an  opening  and  closing  office  door),  she  would 
say,  "Isaac,  I need  you  to  sit  in  your  chair  or  play 
in  this  space  by  mommy's  feet  (pointing).  I am 
nervous  that  the  door  might  bump  into  you."  She 
has  already  moved  toward  the  child  and  obtained 
his  attention.  She  waits  a few  seconds  for  the  child 
to  respond.  If  necessary  she  would  take  him  by 
the  hand  and  guide  him  to  a safer  location.  She 
would  then  remind  him  periodically  to  stay  in  the 
designated  play  space.  In  this  scenario,  the  mother 
implemented  several  antecedent  strategies  de- 
signed to  set  the  occasion  for  prosocial  behaviors. 
For  example,  she  provided  an  enriched  environ- 


ment and  provided  the  child  attention  by  inter- 
acting with  him  while  they  were  waiting.  When 
she  needed  to  redirect,  she  stated  the  rule  and  ra- 
tionale after  increasing  her  proximity  and  obtain- 
ing the  child's  attention,  waited  for  the  child  to 
comply,  and  prepared  to  guide  the  child  to  com- 
ply if  needed. 

Imagine  the  profound  cumulative  effect  of  sev- 
eral hundred  of  these  types  of  parent-child  ex- 
changes throughout  a day.1  Now  imagine  the  pro- 
found effect  of  several  hundred  of  the  coercive 
parent-child  exchanges  occurring  throughout  a 
day.  It  is  no  wonder  that  families  engaged  in  coer- 
cive patterns  of  interaction  are  frustrated,  over- 
whelmed, and  angry.2  Research  indicates  that  these 
early  coercive  patterns  of  parent-child  interaction 
lead  to  mild  forms  of  antisocial  behavior  that  lead 
to  parent  and  peer  rejection,  then  teacher  rejection, 
then  school  failure,  then  forming  associations  with 
maladaptive  peer  groups,  and  eventually  to  drop- 
out, criminality,  and  adult  psychopathology.  This 
robust  sequence  becomes  more  complicated  as  the 
sequence  progresses,  but  the  sequence  in  many 
cases  begins  with  coercive  parent-child  interaction. 

SCOPE  OF  THE  PROBLEM 

Antisocial  behavior  can  be  defined  as  violations 
of  socially  accepted  standards  of  behavior.3  Devi- 
ant social  patterns  are  learned  early  in  life  with 
the  parent  acting  as  the  primary  teacher.  In  most 
cases,  these  children  arrive  at  school  exhibiting 
socially  maladaptive  behaviors  (eg,  aggression  to- 
ward peers  and  adults,  running  away,  classroom 
disruption,  noncompliance,  and  tantruming).  Very 
specific  developmental  patterns  and  family  corre- 
lates place  children  at  great  risk  for  learning  mal- 
adaptive patterns  of  social  interaction  early  in  their 
lives.  For  example,  ineffective  parenting  is  related 
to  aggressive  and  noncompliant  child  behaviors. 
Divorce,  low  SES,  substance  abuse,  marital  discord, 
parent  psychopathology,  and  spousal  abuse  are 
related  to  ineffective  parenting.4'6  In  the  develop- 
ment of  antisocial  behavior,  protective  factors  in- 
clude easy  temperament,  social  skills,  positive 
adult  relationship,  effective  parenting,  prosocial 
peers,  school  atmosphere,  and  high  IQ/ academic 
achievement.  Risk  factors  include  difficult  child 
temperament,  early  aggression,  early  noncompli- 
ance, abusive  and  hostile  parenting,  hyperactiv- 


486  J La  State  Med  Soc  VOL  152  October  2000 


Adolescent  Violence 


ity,  chronic  illness,  family  criminality,  family  sub- 
stance abuse,  and  low  SES  community  factors. 
Early  deviant  behavior  patterns  are  highly  predic- 
tive of  multiple  poor  outcomes  such  as  school  fail- 
ure, dropout,  adult  psychopathology,  and  crimi- 
nality. 

Patterson  and  colleagues  have  conducted 
elaborate  cross-sectional  and  longitudinal  studies, 
over  the  past  30  years,  of  the  developmental 
course,  associated  correlates,  and  most  effective 
treatments  for  child  antisocial  behavior  in  both 
home  and  school  settings.  Patterson2  states  that 
the  parents'  failure  to  teach  reasonable  levels  of 
compliance  generates  a series  of  predictable  events 
that  he  termed  "coercion".  Coercive  parent-child 
interaction  strongly  predicts  the  occurrence  of 
child  antisocial  behavior  and  is  associated  strongly 
with  school  failure  and  poor  peer  relations.  Coer- 
cive parent-child  interaction  places  the  child  and 
family  at  risk  for  multiple  negative  outcomes  (eg, 
child  rejection,  marital  discord  and  dissatisfaction, 
maternal  psychopathology,  school  failure  for  the 
child,  peer  rejection,  and  family  isolation).  Addi- 
tionally, as  coercive  patterns  persist,  the  children 
involved  become  more  difficult  to  manage.2 

This  paper  will  attempt  to  describe  the  devel- 
opmental course  of  children  exhibiting  aggressive 
and  noncompliant  behavior  early  in  their  lives. 
Violence  affects  children  in  multiple  ways.  For 
example,  children  may  witness  violent  crime, 
interspousal  abuse,  hear  gunshots  in  their  neigh- 
borhood, and  sense  their  parents'  fear  in  a dan- 
gerous community.  Understanding  the  depth  and 
course  of  the  effects  of  violence  exhibited  toward 
children  or  observed  by  children  in  the  home  or 
community  is  a noteworthy  topic  that  is  beyond 
the  scope  of  this  paper.  Others  have  provided  ex- 
cellent analyses  of  the  developmental  effects  of 
violence  upon  children7  as  well  as  making  empiri- 
cally based  treatment  recommendations8  to  assist 
children  in  coping  with  the  effects  of  violence. 

This  paper  offers  a specific  focus  on  a variable 
(ie,  coercive  parent-child  interaction)  demon- 
strated to  strongly  affect  the  development  of  child 
antisocial  behaviors.  This  variable  can  be  altered 
with  appropriate  programming.  In  many  cases, 
coercive  parent-child  interactions  may  be  the  pri- 
mary factor  contributing  to  the  development  of 
child  noncompliance  and  aggression,  especially 


with  very  young  children.  As  the  child  becomes 
older,  the  variables  that  maintain  and  further  con- 
tribute to  the  development  of  antisocial  behaviors 
become  more  varied  (eg,  peer  influence,  access  to 
reinforcing  properties  of  criminal  behavior,  peer 
rejection,  and  school  failure).  Additionally, 
parenting  skills  have  been  shown  to  contribute 
independently  to  the  effect  of  violence  upon  chil- 
dren. That  is,  the  unskilled  parent  is  likely  to  com- 
pound the  effects  of  community  violence.  Thus, 
the  case  for  early  parent  training  is  a strong  one. 
This  paper  will  make  recommendations  for  iden- 
tifying effective  treatment  strategies  when  practi- 
tioners observe  coercive  parent-child  interaction 
and  child  noncompliance. 

Home  Setting 

How  to  Recognize  the  Problem.  Parents  of 
noncompliant  and  aggressive  children  are  docu- 
mented as  being  more  permissive,  rejecting,  erratic, 
and  inconsistent;  less  likely  to  monitor  their  child's 
behavior,  more  likely  to  use  poor  communication, 
to  reinforce  inappropriate  behavior,  and  to  ignore 
or  punish  prosocial  behavior.9  Parents  of  noncom- 
pliant children  criticize  their  children  more  and 
provide  little  contingent  positive  attention.2  These 
parents  typically  state  commands  as  questions, 
negotiate,  whine,  plead,  or  nag  their  children  to 
attempt  to  get  their  children  to  comply.  Their  chil- 
dren, in  turn,  are  likely  to  argue,  plead,  attempt  to 
negotiate,  then  eventually  escalate  to  whining, 
tantruming,  extreme  disruption,  and  possibly  ag- 
gressive behavior  exhibited  toward  the  parent. 
When  children  do  not  comply  and  exhibit  the  be- 
haviors just  described,  the  parents  are  likely  to 
threaten  without  follow-through  and  in  turn,  es- 
calate to  harsh,  restrictive,  and  possibly  violent 
punishment  strategies.  These  escalating  patterns 
persist  because  parents  and  children  learn  that  dis- 
playing increasingly  negative  behavior  may  result 
in  desired  outcomes  (eg,  child  compliance  for  the 
adult,  escaping  parent  commands  for  the  child). 

Multiple  studies  have  demonstrated  the  rela- 
tionship between  parent  psychopathology,  parent 
criminality,  poor  parenting,  and  oppositional,  ag- 
gressive child  behavior.24'610  Parents  of  antisocial 
children  frequently  model  violent  and  deviant 
behaviors  in  the  home  setting.  For  example,  fa- 
thers of  antisocial  children  are  more  likely  to  have 


J La  State  Med  Soc  VOL  152  October  2000  487 


Adolescent  Violence 


an  arrest  record  (28%  and  7%  for  matched  con- 
trols).11 Parents  of  noncompliant  and  aggressive 
children  are  more  likely  to  abuse  their  children,12 
and  are  frequently  poor  problem  solvers.11  These 
parents  are  likely  to  have  experienced  school  fail- 
ure and,  therefore,  demonstrate  poor  parent-school 
bonding 

Overt  hostility  and  low  levels  of  marital  satis- 
faction are  associated  with  problematic  child  be- 
havior.4 Distressed  parents  are  less  likely  to  be  con- 
sistent and  more  likely  to  use  coercive  discipline 
techniques.16  Maternal  depression  has  been  linked 
to  child  ADHD,17  conduct  problems,18  social  prob- 
lems,19 and  depression.20  Goodman  and  Brumley19 
specifically  found  that  poor  parenting,  which  was 
associated  with  maternal  depression,  was  predic- 
tive of  child  conduct  problems,  not  the  maternal 
depression  diagnosis  alone.  Depressed  mothers 
are  generally  less  engaged  with  their  children  and 
more  critical  and  nagging.20  One  study  found  that 
the  actual  behavior  of  children  between  the  ages 
of  2 months  and  5 years  did  not  differ  based  on 
presence  or  absence  of  maternal  depression,  but 
maternal  perceptions  of  child  behavior  did.22  Thus, 
depressed  mothers  maintained  a more  negative 
view  of  their  children  than  the  children's  behav- 
ior warranted.21  Depressed  parents  are  more  likely 
to  engage  in  coercive  discipline  patterns,  produce 
children  who  engage  in  higher  rates  of  problem- 
atic behavior  in  the  classroom  (eg,  tantruming, 
fighting,  inattention,  social  withdrawal),  and  pro- 
duce children  who  are  at  greater  risk  for  being 
identified  as  having  mental  health  problems. 

Parent /family  "bonding"  to  social  institutions 
(especially  the  school)  is  critical  to  preventing  de- 
viant behavior.13  The  degree  to  which  a family  is 
socially  isolated  has  been  identified  as  a com- 
pounding factor  contributing  to  child  disruptive 
behavior.  Wahler14  defined  insularity  as  having 
few  and  mainly  aversive  social  contacts.  Low  SES 
families  tend  to  experience  greater  degrees  of  in- 
sularity. Occurrence  of  coercive  parent-child  inter- 
action has  been  shown  to  co-vary  with  number  of 
positive  social  contacts  experienced  by  the  mother 
(ie,  degree  of  insularity)  on  a daily  basis.14  Wahler14 
compared  treatment  efficacy  for  insular  and  non- 
insular  families  and  found  that  both  responded 
similarly  to  treatment,  but  insular  families  failed 
to  maintain  treatment  effects  as  measured  by  di- 


rect observation  by  blind  observers  in  the  home 
setting.  Wahler  and  Dumas15  successfully  trained 
insular  mothers  to  identify  daily  stressors  and  the 
communalities  between  stressors  early  in  the  par- 
ent training  process  to  improve  treatment  out- 
comes for  these  families  (as  measured  by  direct 
observation  of  child  behavior). 

Treatments  that  work  and  some  that  do  not.  Com- 
monly applied  treatments  (eg,  placement  in  spe- 
cial education,  traditional  "talk"  therapy)  are  sur- 
prisingly ineffective.  Measurement  strategies  com- 
monly employed  to  identify  and  formally  assess 
children  in  office  settings  are  frequently  insuffi- 
cient, contributing  to  sub-standard  interclinician 
diagnostic  reliability.  Treatment  integrity,  or  the 
degree  to  which  interventions  are  implemented  as 
planned,  is  rarely  adequate,23,24  and  commonly 
employed  treatment  strategies  consist  of  weak, 
poorly-defined  treatment  packages.3  For  example, 
treatment  frequently  involves  counseling  with  the 
parents  in  an  office  setting  or  talking  with  the 
teacher  outside  of  the  classroom,  when  talking 
alone  has  been  shown  to  be  a generally  weak  and 
ineffective  method  for  producing  actual  behavior 
change.25  Unfortunately,  such  treatments  are  not 
only  ineffective  but  are  likely  to  be  replaced  with 
increasingly  restrictive  treatments.26  In  fact,  in  as 
many  as  75%  of  cases,  children  exhibiting  antiso- 
cial behaviors  are  assigned  to  highly  restrictive  in- 
school and  out-of-school  placements.11  Wagner27 
found  that  almost  50%  of  students  previously  iden- 
tified as  "seriously  emotionally  disturbed"  were 
arrested  within  2 years  of  their  departure  from 
school. 

In  general,  no  specific  form  of  treatment  has 
been  shown  to  be  sufficiently  effective  across  all 
behavior  topographies,  contingencies,  and  situa- 
tions. For  example,  time  out  is  a frequently  ap- 
plied treatment  for  young  children  that  has  been 
shown  to  be  acceptable  to  parents  and  teachers, 
superior  to  alternative  forms  of  punishment  (eg, 
spanking)  in  terms  of  side  effects,  and  effective  in 
reducing  problematic  behaviors  displayed  by 
young  children.  Time  out,  however,  is  not  effec- 
tive in  all  cases.  Consider  for  example  the  young 
child  who  throws  a tantrum  to  get  out  of  a par- 
ticular classroom  activity  or  parent  command  at 
home.  Time  out,  in  this  case,  would  actually  be 
reinforcing  to  the  child,  allowing  the  child  to  es- 


488  J La  State  Med  Soc  VOL  152  October  2000 


Adolescent  Violence 


cape  the  non-preferred  situation  (ie,  math,  sitting 
at  the  dinner  table).  Given  this  example,  time  out 
would  actually  be  contraindicated.  Further,  the 
parameters  of  applied  treatments  should  be  em- 
pirically based.  For  example,  time  out  is  conven- 
tionally applied  at  1 minute  per  year  of  the  child's 
age.  Yet,  this  duration  estimate  is  arbitrary  as  there 
has  been  no  direct  experimental  investigation  of 
time  out  duration.  Duration  of  time  out  should  be 
limited  for  two  reasons.  The  longer  the  child  sits 
in  time  out,  the  greater  the  chance  of  the  child  find- 
ing something  fun  or  entertaining  to  do,  therefore 
decreasing  efficacy  (ie,  time  out  becomes  time  in). 
Second,  time  out  is  a punishment  technique  that 
restricts  the  child's  access  to  learning  opportuni- 
ties and  habilitation. 

Determining  which  treatment  to  select  (eg, 
time  out,  guided  practice,  response  cost,  momen- 
tum) and  planning  the  parameters  of  implemen- 
tation (eg,  duration)  depends  upon  individual 
child  and  family  variables.  Functional  assessment 
involves  identifying  the  potential  "reasons"  for 
why  problem  behaviors  occur.  That  is,  deviant 
behaviors  frequently  serve  some  kind  of  commu- 
nicative function  for  the  child,  resulting  in  the  child 
obtaining  a desired  outcome  by  engaging  in  the 
deviant  behavior.  Treatment  is  designed  to  teach 
the  client  new,  adaptive  ways  of  obtaining  desired 
outcomes  and  to  limit  desirable  outcomes  for  de- 
viant or  maladaptive  behaviors.  Individually  de- 
termined interventions  are  superior  because  they 
identify  conditions  that  promote  initial  onset  of 
problematic  behaviors,  indicate  the  source  of  re- 
inforcement, suggest  specific  reinforcing  events 
that  link  directly  to  a viable  treatment,  and  indi- 
cate treatment  approaches  that  are  likely  to  be  in- 
effective or  counterproductive.28  Whereas  large- 
scale  group  studies  indicate  treatment  strategies 
that  are  likely  to  be  effective  for  most  children, 
individual  treatments  must  be  tested  for  an  indi- 
vidual child  to  determine  whether  or  not  the  treat- 
ment will  be  effective  for  that  particular  child.  This 
demonstration  requires,  at  a minimum,  reliable 
baseline  data  (ie,  pretreatment  occurrence  of  be- 
havior), measurement  of  treatment  integrity  or 
compliance  (ie,  the  degree  to  which  the  treatment 
was  accurately  implemented  as  prescribed),  and 
measurement  of  treatment  effects  (ie,  post-treat- 
ment occurrence  of  the  behavior). 


Much  is  known  about  training  caregivers  to 
accurately  implement  behavior  change  strategies. 
Talking  about  the  problem  in  a meeting  format 
may  be  an  important  first  step  toward  establish- 
ing rapport,  engaging  the  parent  in  the  problem- 
solving process,  assessing  and  increasing  parent 
acceptability  of  treatment  steps,  and  preparing  the 
parent  to  be  trained  to  implement  intervention 
strategies.  Yet,  talking  alone  (ie,  the  traditional  psy- 
chotherapy model)  has  been  shown  in  multiple, 
well-controlled  studies  to  be  an  ineffective  method 
for  producing  actual  behavior  change  and  should 
be  limited.  Rapport-building  occurs  throughout 
the  therapist-family  relationship  and  is  greatly  en- 
hanced as  parents  observe  child  behavior  changes 
and  gain  confidence  in  their  own  abilities  to  pro- 
duce behavior  change  in  their  children.  The  reader 
is  referred  to  Reid,  Parsons,  and  Green25  for  a thor- 
ough review  of  proven  strategies  for  training 
adults  to  implement  interventions.  To  briefly  sum- 
marize, the  research  indicates  that  those  who  live 
and  work  with  the  child  everyday  should  be 
trained  using  direct  instruction  in  the  relevant  set- 
ting (ie,  as  opposed  to  talking  about  the  problem 
in  a counseling  setting).  Caregivers  should  be 
trained  to  a fluency  criterion  using  a combination 
of  modeling,  verbal  rehearsal,  guided  practice  with 
immediate  and  delayed  feedback,  ongoing 
progress  monitoring,  and  performance  feedback 
to  guarantee  treatment  integrity.25 

Parents  should  be  coached  using  proven  train- 
ing methods  to  identify  potential  "reasons"  for 
child  misbehavior.  Parents  should  then  be  taught 
to  limit  potentially  reinforcing  outcomes  for  dis- 
ruptive behaviors  and  to  prompt  and  provide  posi- 
tive outcomes  for  prosocial  behaviors.  Perhaps 
surprisingly  to  some,  parents  frequently  require 
direct  instruction,  modeling,  and  guided  practice 
in  providing  positive  attention  and  praise  to  their 
children.  That  is,  telling  the  parent  that  he  or  she 
should  provide  positive  attention  to  the  child  is 
fruitless  when  the  parent  does  not  know  how  to 
go  about  actually  engaging  in  this  type  of  interac- 
tion with  the  child.  Yes,  some  parents  must  be 
taught  how  to  praise  their  children.  Positive  par- 
ent attention  is  a critical  form  of  feedback  that  com- 
municates to  the  child  that  prosocial  skills  are  val- 
ued and  result  in  pleasant  outcomes.  Many  chil- 
dren have  not  been  encouraged  to  request  desired 


J La  State  Med  Soc  VOL  152  October  2000  489 


Adolescent  Violence 


items  for  example.  Instead,  parents  frequently  pro- 
vide items  to  the  child  either  without  the  child 
asking  or  in  response  to  crying  or  tantruming. 
Thus,  crying  and  tantruming  become  shaped  be- 
haviors (ie,  reliable  and  powerful  methods  for 
obtaining  desired  outcomes).  Multiple  studies 
have  shown  that  teaching  a child  to  request  a de- 
sired item  (either  by  signing  or  speaking)  is  a pow- 
erful means  of  decreasing  disruptive  behavior.29 

Specific  powerful  preventive  antecedent  strat- 
egies, like  prompting  adaptive  communication 
patterns,  can  be  taught.  Working  with  Headstart 
children  and  their  parents,  Barnett1  describes  the 
use  of  scripted  interventions  to  teach  and  prompt 
parents  to  complete  steps  of  an  intervention. 
Barnett1  conducts  baseline  observations  to  deter- 
mine the  parent's  or  teacher's  language  prefer- 
ences and  their  need  for  detail  prior  to  working 
with  the  parent  or  teacher.  Thus,  practitioners  can 
program  for  teacher  or  parent  acceptability  of  the 
intervention  a priori.  Antecedent  manipulations 
are  emphasized  (ie,  precorrection).  Parents  and 
teachers  are  taught  to  provide  interesting  activi- 
ties and  choices.  Again,  parents  frequently  require 
direct  training  to  provide  stimulating  activities  for 
their  children  and  to  view  all  interactions  as  learn- 
ing opportunities.  For  example,  Barnett1  describes 
specific  training  procedures  to  train  parents  to  read 
daily  with  their  children,  providing  a script  for  this 
daily  positive  parent-child  interaction.  This  script 
is  tailored  to  a family's  individual  needs,  altered, 
and  eventually  faded  as  the  parents  learn  to  flu- 
ently read  with  their  child,  fully  engaging  their 
child  in  the  reading  process  (eg,  asking  questions, 
allowing  child  to  turn  the  page,  using  voice,  point- 
ing to  words).  This  daily  parent-child  activity  be- 
comes an  important  training  time  for  children 
during  which  they  learn  critical  prosocial,  lan- 
guage, and  preacademic  skills. 

Once  the  appropriate  treatment  has  been  se- 
lected and  the  parent  trained  to  implement  it,  it  is 
incumbent  upon  the  practitioner  to  assess  treat- 
ment integrity  prior  to  assuming  that  a treatment 
has  been  properly  implemented  without  the  de- 
sired effects.  Multiple  factors  are  known  to  de- 
crease treatment  integrity  (eg,  maternal  depres- 
sion, single  parent  status,  low  SES,  marital  discord, 
frequent  stressors,  and  insularity).6  Interventions 
can  be  planned  to  maximize  the  probability  of 


parent  implementation.  To  increase  treatment  in- 
tegrity, practitioners  should  decrease  the  complex- 
ity of  the  intervention  as  much  as  possible  with- 
out compromising  treatment  strength,  decrease  the 
number  of  adults  responsible  for  performing  the 
intervention,  and  decrease  the  amount  of  time  re- 
quired to  conduct  the  intervention.  Additionally, 
practitioners  should  provide  necessary  materials, 
describe  the  intervention  in  practical  terms,  avoid- 
ing jargon  and  technical  language,  and  consider 
the  caregiver's  philosophies  about  child  develop- 
ment. The  intervention  is  likely  to  be  implemented 
only  if  the  parent  finds  the  intervention  accept- 
able. Acceptability  can  and  should  be  directly  as- 
sessed. Perhaps  most  critically,  the  parent  should 
be  trained  adequately.  Finally,  the  practitioner 
should  collect  data  on  a daily  basis  to  monitor  the 
child's  progress  and  intervention  integrity.  Collect- 
ing reliable  integrity  data  may  require  practitio- 
ner innovation.  For  example,  Penton  and  Witt30 
had  parents  of  students  conduct  a daily  interview 
with  their  child  over  the  phone  and  this  interview 
was  recorded  by  an  answering  machine.  The  re- 
corded interview  provided  direct  evidence  that  the 
intervention  was  carried  out  as  prescribed.  Be- 
cause of  the  effect  of  adult  psychopathology  upon 
parent-child  interaction,  the  parent's  ability  to  ef- 
fectively engage  in  problem  solving  and  the  like- 
lihood of  the  parent  implementing  intervention 
with  the  child,  treatment  of  comorbid  problems 
(eg,  parent  psychopathology)  is  critical. 

Parent  Management  Training2  (PMT)  incorpo- 
rates all  the  components  of  effective  intervention 
just  described.  PMT  typically  consists  of  teaching 
parents  to  identify  potential  "reasons"  for  their 
child's  behaviors,  to  notice  positive  child  behav- 
iors, to  prompt  and  teach  adaptive  and  prosocial 
child  behaviors,  to  encourage  and  reinforce  com- 
pliance, and  to  discourage  by  not  reinforcing  non- 
compliance  and  other  maladaptive  behaviors.  It 
has  been  estimated  that  treatment  requires  ap- 
proximately 32  professional  hours  per  family  to 
achieve  robust  effects.  Multiple  well-controlled 
studies  have  demonstrated  that  PMT  produces 
clinically  significant  improvements  in  teacher  and 
parent  report  of  child  behavior,  direct  observation 
of  child  behavior,  and  institutional  records.  Treat- 
ment effects  have  been  shown  to  surpass  family- 
based  psychotherapy,  attention-placebo  (ie,  dis- 


490  J La  State  Med  Soc  VOL  152  October  2000 


Adolescent  Violence 


cussion),  and  no-treatment  conditions.31  Treatment 
has  resulted  in  the  child's  behavior  occurring  at 
rates  comparable  to  those  of  non-referred  peers, 
and  improvements  have  maintained  for  1 to  3 
years.3'32  Generalized  effects  have  been  observed 
for  other  problematic  behaviors  not  specifically 
focused  on  in  treatment  (eg,  improved  sibling  be- 
havior and  reduced  maternal  depression).3'32  Early 
intervention  is  more  effective  than  intervention 
later  when  the  problem  is  more  severe.33  PMT  has 
decreased  offense  rates  of  adolescent  delin- 
quents.34 Additionally,  parent  training  combined 
with  adolescent-centered  problem  solving  train- 
ing has  achieved  treatment  effects  superior  to  those 
achieved  by  either  method  alone.35 

School  Setting 

How  to  recognize  the  -problem.  Children  who  have 
learned  to  relate  to  their  parents  and  the  world,  in 
the  context  of  coercive  interaction,  experience  sig- 
nificant deficits  in  the  prosocial  skills  critical  to 
school  success.  These  children  are  likely  to  be  iden- 
tified as  experiencing  school  problems  early  in 
their  schooling  careers  but  are  not  likely  to  ben- 
efit from  the  services  that  are  provided  there.  In 
fact,  these  students  are  likely  to  be  exposed  to  a 
series  of  sequentially  ineffective  and  increasingly 
restrictive  treatments.  In  turn,  these  students  ex- 
perience a much  more  pronounced  risk  for  school 
failure,  placement  in  special  education  classrooms, 
and  eventually  dropout  compared  to  same-age  at- 
risk  peers.  For  example,  one  of  the  most  frequently 
applied  punishment  strategies  by  the  school  sys- 
tem is  exclusion.  That  is,  the  student  exhibiting  a 
severe  offense  (eg,  aggression)  may  be  suspended 
from  school  or  unofficially  sent  home.  This  out- 
come, intended  to  be  punishing,  may  actually  be 
reinforcing  to  the  child,  allowing  the  child  to  play 
at  home  and  escape  the  demands  of  the  school 
setting.  For  the  child  who  has  learned  early  pat- 
terns of  coercive  interaction,  this  type  of  "punish- 
ment" sets  the  tone  for  the  development  of  teacher- 
child  coercive  interaction.  That  is,  the  child's  un- 
derstanding that  displaying  increasingly  negative 
behaviors  results  in  desired  outcomes  is  rein- 
forced. Further,  removal  from  the  class  (or  prob- 
lem behaviors  in  the  class)  may  preclude  the  stu- 
dent from  important  classroom  learning  opportu- 
nities contributing  to  early  school  failure. 


However,  it  is  perhaps  a common  misper- 
ception that  chaotic  and  coercive  home  environ- 
ments inevitably  produce  maladaptive  behaviors 
in  the  classroom.  Several  variables  have  been  iden- 
tified that  can  be  altered  to  increase  habilitation 
for  noncompliant  and  aggressive  students.  For  ex- 
ample, lack  of  rule  clarity,  absence  of  consistent 
consequences  for  rule  violations,  and  ineffective 
instruction  practices  in  schools  are  related  to  ag- 
gressive and  noncompliant  child  behaviors.36'37 
Some  suggest  system  contingencies  are  arranged 
such  that  teachers  and  schools  are  encouraged  to 
identify,  classify,  and  separate  students  from  the 
mainstream,38  and  further,  that  the  intended  con- 
sequences of  IDEA  (the  law  ensuring  free  and  ap- 
propriate public  education  to  all  students  and  gov- 
erning the  identification  of  students  and  provision 
of  special  education  services)  have  not  been  real- 
ized. Specifically,  teachers  are  neither  sufficiently 
skilled  nor  motivated  to  educate  students  whose 
behaviors  are  not  consistent  with  the  teacher's 
normative  expectations.23  Traditionally,  practitio- 
ners have  focused  on  the  assessment  of  child  vari- 
ables to  the  exclusion  of  environmental  variables 
that  may  affect  student  performance  in  the  class- 
room setting.  Treatment  is  then  guided  by  prag- 
matism, resource  availability,  or  skill  level  of  the 
treatment  agent  as  opposed  to  adjusting  child-en- 
vironment fit.  Some  of  the  problems  associated 
with  the  current  classification  system  include 
poorly  validated  diagnostic  categories,  failure  to 
implement  legally  mandated  interventions  in  the 
regular  classroom  setting  (ie,  absence  of  treatment 
integrity),  and  overreliance  on  teacher  referral.  The 
goal,  traditionally,  has  been  classification  for  spe- 
cial education  services.  Yet,  multiple  studies  have 
demonstrated  that  placement  in  special  education 
classrooms  does  not  systematically  relate  to  qual- 
ity, quantity,  or  type  of  instructional  activity.39-41 
Following  assessment  and  classification,  the  famil- 
iar scenario  follows  that  the  student  has  been  la- 
beled, but  has  received  no  systematically  linked 
instructional  programming  changes  designed  to 
remediate  deficits  and  train  skills.  This  outcome 
raises  multiple  ethical  and  possibly  legal  concerns 
regarding  the  practice  of  identifying  and  placing 
students  in  programs  that  do  not  improve  student 
outcomes.42 


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Adolescent  Violence 


Perhaps  because  diagnostic  categories  are  some- 
what fluid  and  interclinician  reliability  weak,  prac- 
titioners may  rely  on  teacher  report  to  make  diag- 
nostic decisions.  Teacher  perception  is  important. 
For  example,  it  has  been  demonstrated  that  teach- 
ers may  provide  inferior  instruction  to  students 
whom  they  perceive  as  low-achieving.43  Yet,  the 
reliability  with  which  teachers  make  the  series  of 
judgments  that  result  in  referral,  and  more  times 
than  not  classification,  remains  unclear.  Tolerance, 
perceptions  of  normality,  parent  and  colleague 
influence,  access  to  reinforcing  properties  of  re- 
ferral (ie,  attention,  escape  from  difficult  child), 
and  system  resource  constraints  are  factors  that 
may  introduce  bias  to  the  decision-making  pro- 
cess.44 

These  effects  are  experienced,  perhaps  most 
acutely,  by  students  exhibiting  low-tolerance  be- 
haviors. Among  the  least-tolerated  behaviors  are 
the  disruptive,  externalizing  behaviors  frequently 
exhibited  by  children  engaged  in  coercive  adult- 
child  interaction.45  The  intervention  most  fre- 
quently attempted  by  many  teachers  to  deal  with 
child  noncompliance  and  aggression  is  referral  to 
special  education,46  and  the  resulting  placements 
are  among  the  most  restrictive  for  these  students.11 
Prospective  longitudinal  studies  have  shown  that 
noncompliant  and  aggressive  students  spend  sig- 
nificantly less  time  engaged  in  academic  instruc- 
tion, less  time  engaged  in  structured  play  activity 
on  the  playground,  and  experience  a higher  rate 
of  negative  peer  interaction.  They  experience  a 
much  greater  number  of  discipline  contacts  with 
school  principals  than  at-risk,  matched  control  stu- 
dents (ie,  195  discipline  contacts  for  antisocial 
group  versus  10  discipline  contacts  for  the  control 
group).  A significantly  greater  proportion  of  these 
students  have  repeated  at  least  one  grade  in  school 
(38%  of  antisocial  group  compared  with  5%  of  con- 
trol group)  and  are  much  more  likely  to  have  re- 
ceived special  education  services  at  school.47  These 
divergent  behavior  patterns  were  found  to  be  con- 
sistent across  grades  five  through  seven.48 

Additionally,  when  these  aggressive  and 
noncompliant  students  are  identified  as  "behav- 
ior disordered"  by  special  education  teams,  the 
probability  of  dropout  for  each  student  doubles.49 
It  is  important  to  note  that  demographic  variables, 
referral  source  and  reason,  and  IQ  scores  have  not 


been  found  to  differ  between  "behavior  disor- 
dered" dropouts  and  "behavior  disordered" 
graduates.  However,  the  number  of  previous  drop- 
outs, transfers  to  other  schools,  and  changes  in 
service  placements  (usually  from  less  to  more  re- 
strictive) were  found  to  be  significantly  higher  for 
dropouts  compared  to  graduates.49 

Currently,  the  emphasis  of  school-based  psy- 
chological services  appears  to  be  on  assessing  the 
child  to  determine  whether  or  not  the  child  meets 
criteria  to  receive  special  education  services.  If  the 
student  does  not  qualify  under  a particular  cat- 
egory, the  child  and  teacher  are  not  likely  to  re- 
ceive any  help  at  all.  On  the  other  hand,  if  the  child 
does  qualify,  the  research  indicates  that  the  child 
is  not  likely  to  receive  special  help  as  a function  of 
the  diagnostic  category  to  which  the  child  has  been 
assigned  anyway.  Perhaps  for  these  reasons,  teach- 
ers have  rated  services  provided  by  the  school 
psychologist  as  generally  unhelpful  and  ineffec- 
tive. In  fact,  teacher  ratings  of  school  psycholo- 
gists' effectiveness  decrease  as  teachers  experience 
greater  contact  with  school  psychologists.50 

What  to  do  about  problems  at  school.  Comprehen- 
sive early  intervention  upon  initial  school  entry 
may  be  the  most  powerful  preventive  method 
available.51  Walker  et  al52  describe  an  intervention 
model  called  "First  Step  to  Success".  This  model 
involves  proactive  screening  of  the  entire  enter- 
ing kindergarten  population,  school-based  inter- 
vention that  teaches  prosocial  skills  designed  to 
facilitate  successful  student-teacher  and  student- 
peer  interaction,  and  training  parents  to  become 
partners  in  intervention  (ie,  reducing  coercive  par- 
ent-child interaction  and  facilitating  family-school 
bonding).  Powerful  prevention  strategies  also  in- 
clude increasing  adult  monitoring  in  problem  ar- 
eas during  problem  times,  communicating  class- 
room/school rules  and  expectations  daily,  and 
teaching  students  the  prosocial  skills  that  they  are 
expected  to  perform.53  Disruptive  student  behav- 
ior, as  measured  by  direct  observation,  has  been 
shown  to  be  most  likely  to  occur  when  students 
are  provided  with  materials  that  are  either  too  easy 
or  too  difficult  for  the  them.  Disruptive  behavior 
is  less  likely  to  occur  when  students  are  provided 
materials  that  match  their  instructional  level.54 
Thus,  providing  students  adequate,  effective  in- 
struction is  a powerful  method  for  preventing  dis- 


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Adolescent  Violence 


ruptive  student  behavior.  Most  importantly,  prac- 
titioners should  use  assessment  strategies  that  link 
directly  to  effective  intervention.  Robust  effects  for 
decreased  student  disruptions,  fewer  discipline 
problems,  decreased  dropout  and  suspension 
rates,  increased  academic  engagement,  and  in- 
creased positive  feelings  among  students  and  staff 
have  been  obtained  by  implementing  function- 
based  (individually-determined)  treatment  strat- 
egies in  the  regular  classroom  setting.36 

Once  an  appropriate  intervention  has  been 
planned  to  decrease  disruptive  behavior  and  in- 
crease student  academic  performance  and  the 
teacher  has  been  provided  with  the  necessary  tech- 
nical assistance  to  implement  the  intervention  cor- 
rectly, it  is  again  incumbent  upon  the  practitioner 
to  directly  measure  treatment  integrity  and  post- 
treatment occurrence  of  behavior.  Happe33  found 
that  teachers  implemented  intervention  plans  only 
50%  of  the  time  after  verbally  having  agreed  to  do 
so.  Wickstrom  and  Witt56  found  that  all  29  teach- 
ers in  their  sample  reported  that  they  had  accu- 
rately, consistently,  and  completely  conducted  the 
planned  intervention  following  training,  whereas 
direct  observation  revealed  that  teachers  had 
implemented  interventions  on  only  4%  of  pre- 
scribed occasions.  Fuchs  and  Fuchs57  found  that 
all  participating  teachers  reported  improved  stu- 
dent behavior,  whereas  direct  observation  indi- 
cated that  no  significant  change  in  student  behav- 
ior was  obtained.  Thus,  direct  observation  failed 
to  corroborate  teacher  report.  Therefore,  the  integ- 
rity with  which  interventions  are  implemented58 
and  the  outcomes  of  behavior  change  efforts57 
should  be  directly  measured  and  considered  when 
making  diagnostic  decisions.  Currently  no  require- 
ment exists  to  guarantee  that  students  are  actu- 
ally provided  with  legally-mandated  interventions 
in  the  regular  classroom  setting. 

Because  most  students  exhibiting  deviant  be- 
havior patterns  early  in  their  schooling  years  are 
very  likely  to  contact  special  education  services, 
the  system  of  special  education  service  delivery 
must  also  be  re-evaluated.  Witt  et  al59  described 
an  objective  method  (problem  validation  screen- 
ing) of  identifying  students  who  exhibit  deficient 
behavior  and  academic  skills  and  providing  spe- 
cific help  to  those  students  and  their  teachers  im- 
mediately. Assessment  activities  are  conducted  in 


the  classroom  setting  for  the  most  part,  and  prob- 
lems are  defined  in  terms  of  their  hypothesized 
cause.  Students  are  identified  as  needing  help  if 
their  performance  on  direct  measures  of  math, 
reading,  writing,  and  classroom  behavior  fall  be- 
low national  normative  standards.  The  entire  class 
is  assessed,  and  the  type  of  help  the  student  re- 
ceives depends  on  the  assessment  data.  For  ex- 
ample, if  the  student's  score  falls  below  national 
standards,  but  so  do  the  scores  of  many  of  the 
student's  classmates,  then  a classwide  interven- 
tion is  conducted.  Response  to  intervention  for  the 
entire  class  is  monitored  and  students  who  fail  to 
make  growth  similar  to  that  of  their  classroom 
peers  participate  in  further  assessment.  Classwide 
assessment  may  be  particularly  important  in  Lou- 
isiana where  the  average  student  in  many  school 
districts  routinely  scores  below  national  standards. 
That  is,  perhaps  the  student  identified  by  the 
teacher  exhibits  severe  deficits  in  reading  and 
would  qualify  as  needing  special  services  when 
compared  to  a national  standard.  Yet,  if  the  entire 
class  is  scoring  below  the  national  standard  (ie, 
the  student  does  not  differ  from  his  or  her  peers), 
then  the  problem  could  more  accurately  be  defined 
initially  as  a classwide  or  instruction  problem.  The 
only  way  to  know  whether  or  not  an  individual 
student  in  such  a classroom  truly  has  a problem 
that  merits  special  education  would  be  to  provide 
intervention  to  the  entire  class  and  compare  that 
student's  learning  curve  to  that  of  his  or  her  class- 
mates. 

Problem  validation  screening  calls  for  the  di- 
rect training  of  teachers  to  implement  function- 
based  interventions  in  the  regular  classroom  set- 
ting using  the  methods  described  by  Reid  et  al23 
(verbal  rehearsal,  model,  and  practice  with  feed- 
back sequence  until  the  teacher  independently 
completes  100%  of  the  scripted  intervention  steps 
on  two  consecutive  occasions).  Following  teacher 
training,  integrity  data  are  collected  to  ensure  that 
the  intervention  is  implemented  daily  as  agreed 
by  the  teacher.  Students  who  fail  to  respond  suffi- 
ciently to  this  type  of  intervention  may  proceed  to 
a formal  evaluation  for  special  education.  Follow- 
ing intervention,  the  teacher  attends  a follow-up 
meeting  with  the  school  committee  to  determine 
whether  or  not  the  student's  problems  have  been 
adequately  remediated  to  preclude  formal  evalu- 


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Adolescent  Violence 


ation.  During  this  meeting,  daily  intervention  data 
are  presented  for  committee  consideration.  Dur- 
ing the  first  full  year  of  implementation  in  one 
school  district,  90%  of  the  students  referred  by 
their  teachers  for  consideration  for  special  educa- 
tion did  not  proceed  to  formal  evaluation.  That  is, 
problems  that  were  initially  significant  enough  in 
the  teacher's  mind  to  warrant  referral  to  the 
school's  special  education  committee  were  suc- 
cessfully resolved  with  intervention  as  measured 
by  objective  data  (eg,  number  of  words  read  cor- 
rectly per  minute,  number  of  discipline  contacts 
with  office,  direct  observation  of  behavior  during 
problem  times)  in  90%  of  cases.  On  average,  in 
school  districts  across  the  United  States,  90%  of 
students  referred  for  special  education  services 
participate  in  a formal  evaluation  at  an  estimated 
cost  of  $3000  per  child.  Because  formal  psycho- 
educational  assessments  do  not  provide  data  use- 
ful for  instructional  programming  or  intervention 
planning,  the  result  of  all  the  testing  is  knowing 
only  whether  or  not  a child  "qualifies".  It  is  no 
wonder  that  teachers  rate  psychological  services 
as  ineffective  when  after  multiple  hours  of  testing 
and  many  weeks  of  waiting,  they  receive  no  help 
concerning  specific  strategies  to  attempt  to  resolve 
the  problem. 

In  a large-scale  assessment  of  the  accuracy  of 
the  problem  validation  screening  and  resistance 
to  intervention  model  described  by  Witt  et  al,59 
VanDerHeyden  and  Witt60  found  that  the  problem 
validation  screening  procedure  was  much  more 
accurate  than  teacher  referral  in  identifying  stu- 
dents who  may  need  special  services.  Specifically, 
when  a teacher  nominated  a student  as  needing 
special  help,  the  probability  that  the  student  would 
be  found  to  have  a valid  problem  (ie,  positive  pre- 
dictive power)  was  .19.  When  the  teacher  did  not 
refer  a student  for  special  services,  the  probability 
that  the  student  truly  did  not  need  special  help 
(ie,  negative  predictive  power)  was  .89.  Positive 
predictive  power  for  problem  validation  screen- 
ing was  .53  (several  false  positives  were  obtained). 
Most  importantly,  however,  negative  predictive 
power  was  .96  for  problem  validation  screening. 
Additionally,  these  predictive  power  estimates 
exceeded  base  rate  accuracy  (that  obtained  by 
chance  alone)  and  were  stable  across  low-achiev- 
ing and  high-achieving  classrooms  for  problem 


validation  screening,  whereas  teacher  referral  pre- 
dictive power  estimates  varied  significantly  across 
individual  classrooms  and  by  race. 

The  2000  Kids  Count  data  have  been  published 
and  again  Louisiana  is  not  in  a favorable  position. 
On  nearly  all  the  indicators  of  child  well-being, 
Louisiana  falls  below  the  national  average  and 
among  the  worst  in  the  country.  These  data  call 
for  a review  of  the  current  system  combined  with 
an  effort  at  every  level  to  implement  proven  strat- 
egies, to  quantify  outcomes  (eg,  measurement  of 
treatment  implementation  and  effects),  and  to 
make  changes  in  response  to  those  measures  (ie, 
accountability).  Some  may  conclude  that  the  prob- 
lem is  too  great,  too  complex,  and  too  long  stand- 
ing for  practitioners  to  make  a difference.  Yet,  ef- 
fective strategies  exist.  Making  these  strategies 
accessible  to  parents  and  teachers  is  the  challenge. 

REFERENCES 

1 . Barnett  D.  Interventions  for  Young  Children.  Paper 
presented  at  the  Pupil  Appraisal  Summer  Institute, 
2000. 

2.  Patterson  GR.  Performance  models  for  antisocial 
boys.  Am  Psychol  1986;41:432-444. 

3.  Kazdin  AE.  Treatment  of  antisocial  behavior  in 
children:  current  status  and  future  directions. 
Psychol  Bull  1987;102:187-203. 

4.  Dadds  MR.  Child  behavior  therapy  and  family 
context:  research  and  clinical  practice  with 
maritally  distressed  families.  Child  Pam  Behav  Ther 
1989;11:27-44. 

5.  Forehand  R.  Parental  roles  in  childhood  psycho- 
pathology. In:  Frame  CL,  Matson  fL  (editors). 
Handbook  of  Assessment  in  Childhood  Psychopathology. 
New  York:  Plenum  Press;1986. 

6.  Webster-Stratton  C,  Hammond  M.  Predictors  of 
treatment  outcome  in  parent  training  for  families 
with  conduct  problems  children.  Behav  Ther 
1990;2:153-163. 

7.  Garbarino  J.  Psychological  child  maltreatment:  a 
developmental  view.  Pam  Violence  Abusive 
Relationships  1993;20:307-315. 

8.  Ollendick  TH.  Violence  in  youth:  where  do  we  go 
from  here?  Behavior  therapy's  response.  Behav  Ther 
1996;27:485-514. 

9.  Webster-Stratton  C.  Mother  perceptions  and 
mother-child  interactions:  comparison  of  a clinic- 
referred  and  non-clinic  group.  J Clin  Child  Psychol 
1985;14:334-339. 

10.  Wahler  RG,  Cartor  PG,  Fleischman  J,  et  al.  The 


494  J La  State  Med  Soc  VOL  152  October  2000 


Adolescent  Violence 


impact  of  synthesis  teaching  and  parent  training 
with  mothers  of  conduct-disordered  children.  / 
Abnorm  Child  Psychol  1993;21:425-440. 

11.  Ramsey  E,  Walker  HM.  Family  management 
correlates  of  antisocial  behavior  among  middle 
school  boys.  Behav  Disord  1988;13:187-201. 

12.  Reid  J,  Taplin  P,  Loeber  R.  A social  interactional 
approach  to  the  treatment  of  abusive  families.  In: 
Stewart  R (editor).  Violent  Behavior:  Social  Learning 
Approaches  to  Prediction,  Management,  and  Treatment. 
New  York:  Brunner /Mazel;  1981. 

13.  Webster-Stratton  C.  Strategies  for  helping  early 
school-aged  children  with  oppositional  defiant  and 
conduct  disorders:  the  importance  of  home-school 
partnerships.  School  Psychol  Rev  1993;22:437-457. 

14.  Wahler  RG.  The  insular  mother:  her  problems  in 
parent-child  treatment.  / Appl  Behav  Analy 
1980;13:207-219. 

15.  Wahler  RG,  Dumas  JE.  Attentional  problems  in 
dysfunctional  mother-child  interactions:  an  inter- 
behavioral  model.  Psychol  Bull  1989;105:116-130. 

16.  Dadds  MR,  Sheffield  JK,  Holbeck  JF.  An  exam- 
ination of  the  differential  relationship  of  marital 
discord  to  parents'  discipline  strategies  for  boys  and 
girls.  J Abnorm  Child  Psychol  1990;18:121-129. 

17.  Brown  RT,  Pacini  JN.  Perceived  family  functioning, 
marital  status,  and  depression  in  parents  of  boys 
with  attention  deficit  disorder.  J Learn  Disabil 
1989;22:581-58 7. 

18.  Dumas  JE,  Gibson  JA,  Albin  JB.  Behavioral 
correlates  of  maternal  depressive  symptomatology 
in  conduct-disorder  children.  J Consul  Clin  Psychol 
1989;57:516-521. 

19.  Goodman  SH,  Brumley  HE.  Schizophrenic  and 
depressed  mothers:  relational  deficits  in  parenting. 
Dev  Psychol  1990;26:31-39. 

20.  Miller  L,  Warner  V,  Wickramaratne  P,  et  al.  Self- 
esteem and  depression:  ten  year  follow-up  of 
mothers  and  offspring.  J Affect  Disord  1999;52:41- 
49. 

21.  Rickard  KM,  Forehand  R,  Wells  KC,  et  al.  Factors 
in  the  referral  of  children  for  behavioral  treatment: 
a comparison  of  mothers  of  clinic-referred  deviant, 
clinic  referred  non-deviant,  and  nonclinic  children. 
Behav  Res  Ther  1981;19:201-205. 

22.  Dumas  JE,  Serekitch  WJ.  Maternal  depressive 
symptomatology  and  child  maladjustment:  a 
comparison  of  three  process  models.  Behav  Ther 
1994;25:161-181. 

23.  Walker  HM.  The  assessment  for  integration  into 
mainstream  settings  (AIMS)  assessment  system: 
rationale,  instruments,  procedures,  and  outcomes. 
J Clin  Child  Psychol  1986;15:  55-63. 


24.  Patterson  GR.  Interventions  for  boys  with  conduct 
problems:  multiple  settings,  treatments,  and 
criteria.  J Consult  Clin  Psychol  1974;42:471-481. 

25.  Reid  DH,  Parsons  MB,  Green  CW.  Treating  aberrant 
behavior  through  effective  staff  management:  a 
developing  technology.  In:  Cipani,  Ennio  (editors). 
The  Treatment  of  Severe  Behavior  Disorders:  Behavior 
Analysis  Approaches.  Washington,  DC:  American 
Association  on  Mental  Retardation;  1989. 
[Monographs  of  the  American  Association  on  Mental 
Retardation,  No.  12] 

26.  Mace  FC,  Roberts  ML.  Factors  affecting  selection 
of  behavioral  interventions.  In:  J Reichle  DP,  Wacker 
(editors).  Communication  and  Language  Series:  Vol. 
3.  Communicative  Alternatives  to  Challenging 
Behavior:  Integrated  Functional  Assessment  and 
Intervention  Strategies.  Baltimore,  MD:  Paul  H. 
Brookes;  1986. 

27.  Wagner  M.  The  National  Longitudinal  Transition 
Study.  Palo  Alto,  Calif:  Stanford  Research  Institute; 
1989. 

28.  Iwata  BA,  Vollmer  TR,  Zarcone  JR,  et  al.  Treatment 
classification  and  selection  based  on  behavioral 
function.  In:  Van  Houten  R.  Axelrod  S (editors). 
Behavior  Analysis  and  Treatment.  New  York:  Plenum 
Press;  1993:101-125. 

29.  Carr  EG,  Durand  VM.  Reducing  behavior  problems 
through  functional  communication  training.  J Appl 
Behav  Analy  1985;18:111-126. 

30.  Penton  C,  Witt  JC.  The  use  of  performance  feedback 
and  incentives  with  parents  and  teachers  of 
minority  adolescent  students  to  increase  student 
treatment  compliance  and  academic  achievement. 
Baton  Rouge,  La:  Louisiana  State  University 
[unpublished  master's  thesis]. 

31.  Patterson  GR,  Chamberlain  P,  Reid  JB.  A 
comparative  evaluation  of  parent  training 
procedures.  Behav  Ther  1982;13:638-649. 

32.  Kazdin  AE.  Parent  management  training:  evidence, 
outcomes,  and  issues.  J Am  Acad  Child  Adolesc 
Psychiat  1997;36:1349-1356. 

33.  Ruma  PR,  Burke  RV,  Thompson  RW.  Group  parent 
training:  is  it  effective  for  children  of  all  ages?  Behav 
Ther  1996;27:159-169. 

34.  Bank  L,  Marlowe  JH,  Reid  JB,  et  al.  A comparative 
evaluation  of  parent-training  interventions  for 
families  of  chronic  delinquents.  J Abnorm  Child 
Psychol  1991;19:15-33. 

35.  Webster-Stratton  C,  Hammond  M.  Treating 
children  with  early-onset  conduct  problems:  a 
comparison  of  child  and  parent  training 
interventions.  / Consult  Clin  Psychol  1997;65:93-109. 


J La  State  Med  Soc  VOL  152  October  2000  495 


Adolescent  Violence 


36.  Mayer  GR.  Preventing  antisocial  behavior  in  the 
schools.  / Appl  Behav  Andy  1995;28:467-478. 

37.  Walker  H,  Colvin  G,  Ramsey  E.  Antisocid  Behavior 
in  Schools:  Strategies  and  Best  Practices.  Pacific  Grove, 
Calif:  Brooks /Cole;  1994. 

38.  Ysseldyke  JE,  Algozzine  B,  Epps  S.  A logical  and 
empirical  analysis  of  current  practice  in  classifying 
students  as  handicapped.  Except  Child  1983;50:160- 
166. 

39.  Ysseldyke  JE,  Christenson  SL,  Thurlow,  ML,  et  al. 
Are  different  kinds  of  instructional  tasks  used  by 
different  categories  of  students  in  different  settings? 
School  Psychol  Rev  1989;18:98-111. 

40.  Ysseldyke  JE,  Thurlow  ML,  Christenson  SL,  et  al. 
Time  allocated  to  instruction  of  mentally  retarded, 
learning  disabled,  emotionally  disturbed,  and 
nonhandicapped  elementary  students.  J Spec  Educ 
1987;21:43-55. 

41.  Ysseldyke  JE,  O'Sullivan  PJ,  Thurlow  ML,  et  al. 
Qualitative  differences  in  reading  and  math 
instruction  received  by  handicapped  students. 
RASE  1989;10:14-20. 

42.  Marshall  et  al.,  v.  Georgia.  U.S.  District  Court  for  the 
Southern  District  of  Georgia,  CV  482-233,  June  28, 
1984. 

43.  Brophy  JE,  Good  TL.  Teachers'  communication  of 
differential  expectations  for  children's  classroom 
performance:  some  behavioral  data.  J Educ  Psychol 
1970;61:365-374. 

44.  Kauffman  JM,  Lloyd  JW,  McGee  KA.  Adaptive  and 
maladaptive  behavior:  teachers'  attitudes  and  their 
technical  assistance  needs.  T J Spec  Educ 
1989;23:185-200. 

45.  Nelson  CM,  Rutherford  RB  Jr,  Center  DB,  et  al.  Do 
public  schools  have  an  obligation  to  serve  troubled 
children  and  youth?  Except  Child  1991;57:406-415. 

46.  Witt  JC,  Martens  BK.  Problems  with  problem- 
solving consultation:  A re-analysis  of  assumptions, 
methods,  and  goals.  School  Psychol  Rev  1988;17:211- 
226. 

47.  Walker  HM,  Shinn  MR,  O'Neill  RE,  et  al.  A 
longitudinal  assessment  of  the  development  of 
antisocial  behavior  in  boys:  rationale,  methodology, 
and  first-year  results.  RASE  1987;8:7-16. 

48.  Walker  HM,  Steiber  S,  O'Neill  RE.  Middle  school 
behavioral  profiles  of  antisocial  and  at-risk  control 
boys:  descriptive  and  predictive  outcomes. 
Exceptionality  1990;1:61-77. 

49.  Kortering  LJ,  Blackorby  J.  High  school  dropout  and 
students  identified  with  behavioral  disorders.  Behav 
Disord  1992;18:24-32. 

50.  Severson  HH,  Pickett  M,  Hetrick  DJ.  Comparing 
preservice,  elementary,  and  junior  high  teachers' 
perceptions  of  school  psychologists:  two  decades 


later.  Psychol  Schools  1985;22:179-186. 

51.  Zigler  E,  Taussig  C,  Black  Y.  Early  childhood 
intervention:  a promising  preventative  for  juvenile 
delinquency.  Am  Psychol  1992;47:997-1006. 

52.  Walker  HM,  Severson  HH,  Feil  EG,  et  al.  First  step 
to  success:  intervening  at  the  point  of  school  entry 
to  prevent  antisocial  behavior  patterns.  Psychol 
Schools  1998;35:259-269. 

53.  Witt  JC,  LaFleur  L,  Naquin  G,  et  al.  Teaching  Effective 
Classroom  Routines.  Longmont,  Colo:  Sopris  West; 
1999. 

54.  Gickling  EE,  Armstrong  DL.  Levels  of  instructional 
difficulty  as  related  to  on-task  behavior,  task 
completion,  and  comprehension.  J Learn  Disahil 
1978;11:32-39. 

55.  Happe  D.  Behavioral  intervention:  it  doesn't  do  you 
any  good  in  your  briefcase.  In:  Grimes  J (editor). 
Psychological  Approaches  to  Problems  of  Children  and 
Adolescents.  Des  Moines,  Iowa:  Iowa  Department 
of  Public  Instruction;  1982:15-41. 

56.  Wickstrom  KF,  Jones  KM,  LaFleur  LH,  et  al.  An 
analysis  of  treatment  integrity  in  school-based 
behavioral  consultation.  School  Psychol  Quart 
1998;13:141-154. 

57.  Fuchs  D,  Fuchs  LS.  Mainstream  assistance  teams 
to  accommodate  difficult-to-teach  students  in 
general  education.  Nashville,  Term:  Department  of 
Special  Education,  George  Peabody  College  for 
Teachers. 

58.  Gresham  FM,  Gansle  KA,  Noell  GH,  et  al. 
Treatment  integrity  of  school-based  behavioral 
intervention  studies:  1980-1990.  School  Psychol  Rev 
1993;22:254-272. 

59.  Witt  J,  Daly  E,  Noell  G.  Functional  Assessments. 
Longmont,  Colo:  Sopris  West;  2000. 

60.  VanDerHeyden  AM,  Witt  JC.  Comparison  of 
several  methods  for  identifying  students  in  need 
of  special  services  in  the  schools:  accuracy  of  the 
problem  validation  screening  model.  Baton  Rouge, 
La:  Louisiana  State  University  [unpublished 
doctoral  dissertation]. 


Dr  Witt,  Professor  of  Psychology  at 
Louisiana  State  University  in  Baton  Rouge,  Louisiana, 
is  the  author  of  14  books  and  approximately  100  journal 
articles.  In  recognition  of  his  accomplishments,  he  was 
awarded  the  Louisiana  State  University 
Alumni  Association  Distinguished  Professor  Award. 

Ms  Vanderheyden  is  completing  a doctorate  degree  in 
school  psychology  at  Louisiana  State  University  under  the 
direction  of  Dr  Witt.  Her  interests  include  prevention, 
functional  assessment,  and  treatment  of  severe  behavior 
problems  exhibited  by  young  children. 


496  J La  State  Med  Soc  VOL  152  October  2000 


Adolescent  Violence 


A Developmental  Psychopathology  Approach 
to  Understanding  and  Preventing 
Youth  Violence 

Paul  J.  Frick,  PhD 


There  are  many  views  in  both  the  lay  and  professional  literatures  as  to  the  causes  of  violent 
behavior.  These  views  influence  the  types  of  interventions  that  are  designed  and  tested  for 
preventing  violence  or  for  treating  violent  individuals.  In  this  paper,  the  author  provides  a 
developmental  psychopathology  framework  in  which  violent  behavior  is  viewed  as  a devel- 
opmental outcome  that  can  result  from  many  different  pathways,  each  involving  a somewhat 
different  interaction  of  causal  processes.  This  way  of  viewing  violent  behavior  has  already 
helped  to  guide  some  of  the  more  effective  prevention  and  treatment  strategies,  with  the  key 
to  their  success  being  a comprehensive  and  individualized  approach  to  intervention.  This  ap- 
proach for  understanding  violent  behavior  also  points  the  way  to  some  important  goals  for  a 
next  generation  of  prevention  and  treatment  programs. 


HOW  WE  THINK  ABOUT  YOUTH  VIOLENCE 

In  recent  years,  there  have  been  several  inci- 
dences of  horrific  violent  acts  committed  by  our 
nation's  youth.  Often,  these  incidents  are  accom- 
panied by  a public  outcry  about  the  conditions 
in  our  society  that  led  these  youth  to  act  vio- 
lently and  the  need  to  take  steps  to  prevent  such 
acts  from  occurring  again.  From  these  public 
discussions,  it  is  clear  that  there  is  no  shortage 
of  "theories"  by  the  lay  public  as  to  what  can 
lead  to  violent  behavior  in  children  including 
inadequate  rearing  environments,  alcohol  and 
drug  use,  bullying  and  teasing  by  peers,  and  the 


availability  of  guns,  to  name  just  a few.  The 
"choice"  as  to  the  critical  factor  often  is  based 
on  philosophical  ideals  and  political  agendas 
rather  than  on  a review  of  the  available  scien- 
tific research  and  these  choices  can  have  a dra- 
matic effect  on  which  violence  prevention  pro- 
grams are  developed  and  funded. 

Across  the  social  and  biological  sciences, 
there  is  large  body  of  research  systematically 
studying  the  various  causal  factors  that  can  lead 
children  and  adolescents  to  act  antisocially  and 
aggressively.  Although  this  information  is  based 
on  scientific  studies,  much  of  this  research  is  also 


J La  State  Med  Soc  VOL  152  October  2000  497 


Adolescent  Violence 


limited  in  scope.  Namely,  the  causes  that  are 
studied  and  viewed  as  most  critical  in  the  de- 
velopment of  violent  behavior  are  often  disci- 
pline dependent  (eg,  sociologists  studying  so- 
ciocultural processes;  medical  professionals 
studying  biological  or  neurological  processes)  or, 
within  a discipline,  dependent  on  a researcher's 
theoretical  orientation  (eg,  social  learning  theo- 
rists studying  problematic  socializing  environ- 
ments, psychodynamic  theorists  studying  intra- 
psychic processes).  This  type  of  research  has 
made  it  difficult  to  develop  integrative  theories 
that  incorporate  the  interactions  of  a number  of 
different  types  of  causal  factors  that  may  be  op- 
erating in  the  development  of  aggressive  and 
violent  behavioral  patterns  and  this,  in  turn,  has 
resulted  in  approaches  to  intervention  that  tend 
to  also  be  limited  in  their  focus.1 

In  recent  years,  there  has  been  an  emerging 
approach  to  understanding  emotional  and  be- 
havioral disturbances,  including  antisocial  and 
aggressive  behavior,  that  uses  our  knowledge  of 
normal  developmental  processes  (eg,  emotional 
regulation)  and  applies  this  knowledge  to  un- 
derstanding how  these  processes  may  go  awry 
and  result  in  maladaptive  psychological  out- 
comes (eg,  poor  anger  control).2  This  approach 
is  labeled  a "developmental  psychopathology" 
orientation  and  there  are  several  aspects  of  this 
orientation  that  have  great  potential  for  advanc- 
ing our  understanding  of  how  children  and  ado- 
lescents develop  tendencies  toward  violent  be- 
havior. First,  developmental  theory  explicitly 
recognizes  that  most,  if  not  all  developmental 
outcomes,  whether  they  be  normal  or  pathologi- 
cal, are  a result  of  a complex  interplay  of  socio- 
cultural, biological,  and  intrapsychic  processes. 
Since  these  processes  are  interdependent,  a fo- 
cus on  any  single  process  will  be  severely  lim- 
ited in  explaining  any  developmental  outcome. 
Second,  developmental  theory  recognizes  that 
the  same  developmental  processes  (eg,  a permis- 
sive rearing  environment)  may  result  in  many 
different  developmental  outcomes  (eg,  some 
children  who  are  creative,  others  who  are  de- 
pendent, and  others  who  are  antisocial),  a con- 
cept called  "multifinality" . The  complementary 


concept,  and  one  that  has  been  particularly  use- 
ful in  guiding  research  in  antisocial  behavior,  is 
"equifinality" . Equifinality  refers  to  the  concept 
that  the  same  outcome  (eg,  antisocial  behavior) 
can  result  from  very  different  developmental 
processes  across  individuals. 

These  are  just  a few  basic  concepts  from  the 
developmental  psychopathology  approach,  but 
they  serve  to  illustrate  some  of  the  important  im- 
plications this  approach  can  have  for  how  re- 
search is  conducted  in  studying  the  causes  of 
violent  behavior.  This  orientation  suggests  that 
research  must  focus  on  uncovering  how  various 
processes  might  interact  in  the  development  of 
antisocial  and  violent  behavior  and  how  these 
interactions  may  differ  across  subgroups  of  vio- 
lent and  antisocial  individuals.  These  different 
interactions  are  referred  to  as  distinct  develop- 
mental pathways  that  can  lead  to  antisocial  out- 
comes. This  approach  also  recognizes  that  the 
same  processes  that  lead  to  violent  behavior  in 
some  individuals  may  lead  to  different  outcomes 
in  other  individuals.  Therefore,  the  processes 
involved  in  the  development  of  antisocial  behav- 
ior in  certain  of  these  causal  pathways  (eg,  pref- 
erence for  novel  and  dangerous  activities)  may 
not  be  specific  to  antisocial  and  violent  individu- 
als. Finally,  and  most  importantly,  if  there  are 
multiple  pathways  leading  to  violent  behavior, 
each  involving  somewhat  different  causal  pro- 
cesses, then  it  is  unlikely  that  a single  approach 
to  intervention  will  be  equally  effective  across 
the  different  pathways.  Instead,  the  interven- 
tions need  to  be  tailored  to  the  differing  processes 
operating  in  each  pathway. 

RESEARCH  ON 

DEVELOPMENTAL  PATHWAYS  TO 
ANTISOCIAL  BEHAVIOR  PATTERNS 

This  developmental  psychopathology  approach 
can  be  illustrated  in  some  of  the  recent  research 
on  children  and  adolescents  who  receive  the  di- 
agnosis of  Conduct  Disorder  (CD).3  CD  is  a psy- 
chiatric definition  describing  children  or  adoles- 
cents who  show  a chronic  pattern  of  aggressive 
and  antisocial  behavior  in  which  the  basic  rights 


498  J La  State  Med  Soc  VOL  152  October  2000 


Adolescent  Violence 


of  others  are  violated  (eg,  violence  towards  oth- 
ers, destruction  of  property)  or  major  age  appro- 
priate norms  are  violated  (eg,  truancy,  running 
away  from  home  overnight),  irrespective  of  what 
causes  this  behavioral  pattern.  Typically,  the 
most  severely  violent  individuals  and  those  who 
are  brought  to  the  attention  of  the  juvenile  court 
system  for  severe  or  chronic  offending  would 
meet  the  criteria  for  this  disorder. 

Childhood-onset  vs.  Adolescent-onset  Pathways. 
Within  those  chronically  antisocial  youth  who 
either  have  been  diagnosed  or  could  be  diag- 
nosed with  CD,  there  appears  to  be  an  impor- 
tant distinction  between  two  groups  of  youth. 
One  group  begins  showing  severe  conduct  prob- 
lems prior  to  adolescence,  often  as  early  as  pre- 
school or  early  elementary  school,  and  their  be- 
havioral problems  increase  in  rate  and  severity 
over  the  childhood  years.4  In  contrast  to  this 
childhood-onset  group,  there  is  a second  group 
who  do  not  show  significant  behavioral  prob- 
lems in  childhood  but  begin  exhibiting  signifi- 
cant conduct  problems  as  they  enter  adoles- 
cence.5 One  of  the  key  differences  between  these 
two  groups  of  antisocial  youth  is  that  the  child- 
hood-onset  group  is  much  more  likely  to  con- 
tinue to  show  antisocial  and  criminal  behavior 
through  adolescence  and  into  adulthood  com- 
pared to  the  adolescent-onset  group.6  However, 
in  addition  to  the  differences  in  prognosis,  re- 
search has  uncovered  several  other  characteris- 
tics that  could  suggest  the  operation  of  different 
causal  processes  underlying  the  antisocial  be- 
havior of  the  two  groups. 

Specifically,  children  in  the  childhood-onset 
group  are  characterized  by  more  aggression, 
higher  rates  of  cognitive  (eg,  lower  verbal  intel- 
ligence) and  neuropsychological  (eg,  executive 
functioning  deficits)  dysfunction,  more  distur- 
bances in  their  autonomic  nervous  system  func- 
tioning, and  more  severe  problems  of  impulse 
control,  often  leading  to  higher  rates  of  diagno- 
sis of  Attention-deficit  Hyperactivity  Disorder, 
than  children  with  the  adolescent-onset  pattern 
of  CD.5  7 The  two  patterns  of  antisocial  behavior 
also  appear  to  be  associated  with  different  per- 
sonality traits.  The  childhood-onset  group  shows 


a personality  profile  characterized  by  impulsive 
and  impetuous  behavior  and  a cold,  callous, 
alienated,  and  suspicious  interpersonal  style.  In 
contrast,  children  showing  the  adolescent-onset 
pattern  seem  to  desire  more  close  relationships 
with  others,  yet  tend  to  reject  traditional  status 
hierarchies  and  religious  rules.8  In  addition,  chil- 
dren with  the  childhood-onset  pattern  of  anti- 
social behavior  seem  to  come  from  much  more 
dysfunctional  family  environments,  character- 
ized by  a higher  rate  of  parental  psychopathol- 
ogy, a higher  rate  of  family  conflict,  and  more 
ineffective  parenting  practices  than  the  adoles- 
cent-onset group.5'7 

These  differences  illustrate  how  the  distinct 
characteristics  across  subgroups  of  antisocial 
children  can  cut  across  biobehavioral,  interper- 
sonal, and  sociocultural  factors.  Also,  the  differ- 
ent pattern  of  characteristics  suggests  that  the 
adolescent-onset  group  seems  to  show  fewer 
pathogenic  deficits  across  each  of  these  levels 
and  this  has  led  to  the  suggestion  that  they  show 
a less  severe  and  characterological  dysfunction 
than  the  childhood-onset  group.5  Specifically, 
some  level  of  rebellious  and  antisocial  behavior 
is  normative  in  adolescence  and  this  is  related 
to  the  adolescent's  struggle  to  develop  his  or  her 
own  unique  identity  that  is,  at  least  partly,  inde- 
pendent of  their  parents  and  society.  Engaging 
in  forbidden  behaviors  can  engender  feelings  of 
independence  and  maturity,  albeit  in  a some- 
what misguided  manner.  Therefore,  the  adoles- 
cent-onset group  may  represent  an  exaggeration 
of  this  normative  developmental  process,  an  ex- 
aggeration that  is  due  to  a child's  tendency  to 
already  be  more  rebellious  and  rejecting  of  au- 
thority than  other  youth. 

Callous-unemotional  vs.  Impulsive  Pathways.  In 
contrast,  the  childhood-onset  group  appears  to 
show  a number  of  more  severe  pathogenic  pro- 
cesses that  seem  to  indicate  that  their  problems 
are  not  simply  an  exaggeration  of  a normative 
developmental  process.  However,  there  appears 
to  be  some  important  distinctions  that  can  be 
made  within  this  group  in  terms  of  the  types  of 
pathogenic  processes  that  may  be  operating.  The 
distinction  is  based  on  differentiating  between 


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Adolescent  Violence 


children  who  show  a callous  and  unemotional 
interpersonal  style  and  those  who  do  not.  Cal- 
lous-unemotional (CU)  traits  refer  to  a lack  of 
guilt  over  misdeeds,  a lack  of  empathy  towards 
others,  and  a general  lack  of  emotionality.9  Chil- 
dren with  conduct  problems,  who  also  show 
these  traits,  tend  to  be  more  thrill  and  adven- 
ture seeking,10  are  less  sensitive  to  the  effects  of 
punishment  compared  to  the  effects  of  rewards,11 
and  are  less  reactive  to  threatening  and  emotion- 
ally distressing  stimuli12  than  other  children  with 
childhood-onset  conduct  problems  group. 

All  of  these  characteristics  are  consistent  with 
a temperamental  style  associated  with  low  emo- 
tional reactivity  that  is  characterized  physiologi- 
cally by  underreactivity  in  the  autonomic  ner- 
vous system  and  behaviorally  by  low  fearfulness 
to  novel  or  threatening  situations  and  poor  re- 
sponsiveness to  cues  to  punishment.13  Develop- 
mental research  has  shown  that  this  tempera- 
ment can  be  related  to  the  development  of  CU 
traits  in  several  ways.14  For  example,  this  tem- 
perament could  place  a child  at  risk  for  missing 
some  of  the  early  precursors  to  empathetic  con- 
cern which  involve  emotional  arousal  evoked  by 
the  misfortune  and  distress  of  others,  it  could 
lead  a child  to  be  relatively  insensitive  to  the 
prohibitions  and  sanctions  of  parents  and  other 
socializing  agents,  and  it  could  create  an  inter- 
personal style  in  which  the  child  becomes  so  fo- 
cused on  the  potential  rewards  and  gains  in- 
volved in  using  aggression  to  solve  interpersonal 
conflicts  that  he  or  she  ignores  the  potentially 
harmful  effects  of  this  behavior  on  him  or  her- 
self and  others.  Research  supports  these  poten- 
tial mechanisms  in  showing  that  antisocial  and 
delinquent  youth  who  show  CU  traits  are  less 
distressed  by  the  negative  effects  of  their  behav- 
ior on  others,  are  more  impaired  in  their  moral 
reasoning  and  empathic  concern  towards  oth- 
ers, and  expect  more  instrumental  gain  (eg,  ob- 
taining goods  or  social  goals)  from  their  aggres- 
sive actions  than  antisocial  youth  without  these 
traits.10' 12' 15  Possibly  because  of  their  lack  of  emo- 
tionality, when  these  youth  commit  violent  acts 
they  tend  to  be  more  premeditated  and  preda- 
tory including  violent  sexual  offenses,  the  vio- 


lent acts  are  more  likely  to  have  sadistic  motiva- 
tions, they  are  more  likely  to  have  multiple  vio- 
lent acts  against  the  same  person,  and  the  vio- 
lence is  more  likely  to  result  in  severe  injury  to 
the  victims.1617 

In  contrast  to  those  youth  with  CU  traits, 
those  youth  within  the  childhood-onset  group 
who  do  not  show  these  traits  tend  to  show  the 
opposite  extreme  of  emotional  reactivity.  They 
tend  to  be  highly  reactive  to  emotional  and 
threatening  stimuli18  and  they  tend  to  respond 
more  strongly  to  provocations  in  social  situa- 
tions.15 Also,  their  aggressive  and  antisocial  be- 
havior is  more  strongly  associated  with  dysfunc- 
tional parenting  practices19  and  with  deficits  in 
verbal  intelligence20  than  the  group  that  is  high 
on  CU  traits.  These  findings  suggest  that  chil- 
dren with  a childhood-onset  to  their  antisocial 
behavior  but  who  do  not  show  high  rates  of  CU 
traits  may  have  problems  more  specifically  as- 
sociated with  poor  behavioral  and  emotional 
regulation  characterized  by  very  impulsive  be- 
havior and  high  levels  of  emotional  reactivity. 
Such  poor  emotional  regulation  can  result  from 
a number  of  interacting  causal  factors,  such  as 
inadequate  socialization  in  their  rearing  environ- 
ments, deficits  in  their  verbal  intelligence  which 
make  it  difficult  for  them  to  delay  gratification 
and  anticipate  consequences,  or  temperamental 
problems  in  response  inhibition.  The  problems 
in  emotional  regulation  can  lead  to  very  impul- 
sive and  unplanned  aggressive  acts  for  which 
the  child  may  be  remorseful  afterwards  but  for 
which  he  or  she  still  has  difficulty  controlling.  It 
can  also  lead  to  a child  being  susceptible  to  be- 
coming angry  (ie,  emotionally  aroused)  due  to 
perceived  provocations  from  peers  leading  to 
violent  and  aggressive  acts  within  the  context  of 
high  emotional  arousal. 

IMPLICATIONS  FOR  TREATMENT 

This  research  on  some  of  the  distinct  develop- 
mental pathways  underlying  antisocial  and  vio- 
lent behavior  illustrates  why  the  vast  majority 
of  interventions  designed  to  prevent  violence  or 
treat  violent  individuals  have  not  proven  to  be 


500  J La  State  Med  Soc  VOL  152  October  2000 


Adolescent  Violence 


very  effective.21  Most  of  these  interventions  have 
focused  on  single  processes  (eg,  inadequate 
parenting,  poor  anger  control)  and  it  is  clear  that 
within  any  of  the  pathways  outlined  above  there 
are  multiple  processes  involved  in  the  develop- 
ment of  antisocial  behavior.  Even  some  of  the 
more  comprehensive  interventions  have  ne- 
glected the  need  to  tailor  the  interventions  across 
the  different  subgroups  of  children  with  CD.22 
Very  few  have  attempted  to  use  a comprehen- 
sive and  individualized  approach  to  interven- 
tion that  seems  to  fit  best  with  our  unfolding  un- 
derstanding of  how  children  develop  tendencies 
toward  violent  and  antisocial  behavior. 

One  notable  exception  is  Multi-Systemic 
Therapy  (MST)  which  is  a comprehensive  ap- 
proach to  the  treatment  of  CD  that  was  designed 
to  be  flexible  in  its  implementation  so  that  treat- 
ment is  tailored  to  the  needs  of  the  individual 
child  and  his  or  her  family.23  This  approach  is 
one  of  the  few  interventions  that  has  proven  to 
be  successful  for  treating  severely  antisocial  chil- 
dren and  adolescents  in  controlled  treatment  out- 
come studies.24  To  encourage  further  develop- 
ment of  these  types  of  intervention,  I have  tried 
to  provide  a more  general  framework  for  imple- 
menting this  type  of  intervention  that  can  be 
used  by  mental  professionals  in  many  different 
settings."  Also,  the  Center  for  the  Study  and  Pre- 
vention of  Violence  has  identified  10  promising 
programs,  including  MST,  that  have  met  rigor- 
ous standards  of  demonstrating  program  effec- 
tiveness in  the  prevention  of  violence,  and  this 
center  provides  a blueprint  and  technical  sup- 
port for  agencies,  both  public  and  private,  who 
would  want  to  implement  these  programs  in 
their  communities.25  Besides  providing  a gen- 
eral framework  for  intervention,  the  develop- 
mental psychopathology  approach  to  under- 
standing violence  also  provides  some  guidance 
for  improving  our  treatment  technology  even 
further.  For  example,  the  major  interventions 
that  have  been  systematically  developed  and 
tested  to  date  in  the  treatment  of  antisocial  be- 
havior, such  as  contingency  management  pro- 
grams, parenting  interventions,  and  anger  con- 
trol training,1  each  of  which  forms  the  nucleus 


of  many  comprehensive  approaches  to  treat- 
ment,22 seem  to  target  processes  that  are  most 
important  in  the  development  of  antisocial  be- 
havior in  only  one  of  the  developmental  path- 
ways summarized  previously.  That  is,  these  are 
primarily  designed  to  alter  processes  that  are 
most  strongly  associated  with  the  impulsive- 
type  within  the  childhood-onset  category.  This 
statement  is  purely  conjecture  at  this  point,  since 
no  study  has  systematically  compared  the  effec- 
tiveness of  interventions  across  the  different  sub- 
groups of  antisocial  or  delinquent  youth.  How- 
ever, clearly  there  is  a need  to  develop  and  test 
interventions  that  more  specifically  focus  on  the 
processes  that  seem  to  underlie  the  adolescent- 
onset  subgroup  (eg,  helping  a child  to  develop 
more  adaptive  ways  of  meeting  maturity  and 
identity  needs)  and  that  focus  on  the  processes 
that  seem  to  underlie  the  callous-unemotional 
type  of  the  childhood-onset  group  (eg,  capital- 
izing on  a reward-oriented  response  style,  com- 
pensating for  a lack  of  empathetic  concern  for 
others). 

In  conclusion,  it  is  evident  that  interventions 
for  the  prevention  of  violence  or  for  the  treat- 
ment of  violent  individuals  is  quite  dependent 
on  the  prevailing  views  of  the  causes  of  violent 
behavior.  I have  tried  to  outline  some  of  the  in- 
triguing findings  resulting  from  a developmen- 
tal psychopathology  perspective  for  understand- 
ing such  behavior,  and  these  findings  have  al- 
ready helped  to  shape  several  of  the  more  suc- 
cessful approaches  to  intervention.  Hopefully, 
there  will  be  many  refinements  and  additions  to 
the  developmental  pathways  that  were  de- 
scribed in  this  paper  as  research  advances.  And, 
if  interventions  continue  to  be  informed  by  such 
research,  their  success  in  reducing  the  incidence 
and  prevalence  of  violence  is  likely  to  continue 
to  advance  as  well.  However,  utilizing  this  per- 
spective does  require  a change  in  how  the  lay 
public  has  traditionally  viewed  violence  as  a so- 
cietal concern  and  allocated  resources  accord- 
ingly. Similarly,  it  requires  a change  in  how  many 
mental  health  and  medical  professionals  have 
viewed  violence  and  designed  treatments  based 
on  this  view.  The  developmental  psychopatho- 


J La  State  Med  Soc  VOL  152  October  2000  501 


Adolescent  Violence 


logical  perspective  provides  a somewhat  more 
complex  view  of  the  problem  than  is  typically 
taken  by  either  professionals  or  the  lay  public, 
but  it  is  a perspective  that  recognizes  the  com- 
plexity involved  in  any  developmental  outcome, 
normal  or  abnormal,  including  the  development 
of  tendencies  to  act  violently. 

ACKNOWLEDGEMENTS 

Work  on  this  manuscript  was  supported  by  grant 
R29  Ml  155654-02  from  the  National  Institute  of 
Mental  Health. 

REFERENCES 

1.  Frick  PJ.  A comprehensive  and  individualized 
treatment  approach  for  children  and  adolescents 
with  conduct  disorders.  Coy  Behav  Practice 
2000;7:30-37. 

2.  Cicchetti  D.  Developmental  psychopathology: 
reactions,  reflections,  projections.  Dei’  Rev 
1993;13:137-141. 

3.  American  Psychiatric  Association.  Diagnostic  amt 
Statistical  Manual  of  Mental  Disorders , 4th  edition. 
Washington,  DC:  American  Psychiatric  Press;  1094. 

4.  Lahey  BB,  Loeber  R.  Framework  for  a 
developmental  model  of  oppositional  defiant 
disorder  and  conduct  disorder.  In:  Routh  DK 
(editor).  Disruptive  Behavior  Disorders  in  Childhood. 
New  York:  Plenum;  1994:139-180. 

5.  Moffitt  TE.  Adolescence-limited  and  life-course 
persistent  antisocial  behavior:  a developmental 
taxonomy-  Psychol  Rev  1993;100:674-701. 

6.  Frick  PJ,  Loney  BR.  Outcomes  of  children  and 
adolescents  with  conduct  disorder  and  oppositional 
defiant  disorder.  In:  Quay  HC,  Hogan  A.  (editors) 
Handbook  of  Disruptive  Behavior  Disorders.  New  York: 
Plenum;  1999:507-524. 

7.  Frick  PJ.  Conduct  Disorders  and  Severe  Antisocial 
Behavior.  New  York:  Plenum;  1998. 

8.  Moffitt  TE,  Caspi  A,  Dickson  N,  et  al.  Childhood- 
onset  versus  adolescent-onset  antisocial  conduct 
problems  in  males:  natural  history  from  ages  3 to 
18  years.  Development  and  Psychopathology 
1996;8:399-424. 

9.  Frick  PJ,  Bodin  SD,  Barry  CT.  Psychopathic  traits 
and  conduct  problems  in  community  and  clinic- 
referred  samples  of  children:  further  development 
of  the  Psychopathy  Screening  Device.  Psychol  Assess 
[in  press.] 

10.  Frick  PJ,  Lilienfeld  SO,  Ellis  M,  et  al.  The  association 
between  anxiety  and  psychopathy  dimensions  in 

502  J La  State  Med  Soc  VOL  152  October  2000 


children.  / Aim  Ch  Psychol  1999;27:381-390. 

11.  O'Brien  BS,  Frick  PJ.  Reward  dominance: 
associations  with  anxiety,  conduct  problems,  and 
psychopathy  in  children.  / Abn  Ch  Psychol 
1996;24:223-240. 

12.  Blair  RJR.  Responsiveness  to  distress  cues  in  the 
child  with  psychopathic  tendencies.  Person  hid  Diff 
1999;27:135-145. 

13.  Kagan  J,  Snidman  N.  Temperamental  factors  in 
human  development.  American  Psychologist 
1991;46:6-862. 

14.  Kochanska  G.  Toward  a synthesis  of  parental 
socialization  and  child  temperament  in  early 
development  of  conscience.  Child  Development 
1993;64:325-34 7. 

15.  Pardini  DA,  Lochman  JE,  Frick  PJ.  Callous- 
unemotional  traits  in  social  cognitive  processes  in 
adjudicated  youth.  Manuscript  under  editorial 
review;  2000. 

16.  Caputo  A A,  Frick  PJ,  Brodsky  SL.  Family  violence 
and  juvenile  sex  offending:  potential  mediating 
roles  of  psychopathic  traits  and  negative  attitudes 
toward  women.  Crim  Justice  Behav  1999;26:338-356. 

17.  Kruh  IP,  Frick  PJ,  Clcements  CB.  Actuarial  and 
personality  predictors  of  violence  patterns  in 
incarcerated  youth.  Manuscript  under  editorial 
review;  2000. 

18.  Loney  BR,  Frick  PJ,  Ellis,  ML.  Emotional  reactivity 
and  callous  unemotional  traits  in  adolescents. 
Manuscript  submitted  for  publication;  2000. 

19.  Wootton  JM,  Frick  PJ,  Shelton  KK,  et  al.  Ineffective 
parenting  and  childhood  conduct  problems:  the 
moderating  role  of  callous-unemotional  traits.  / 
Consul  Clin  Psychol  1997;65:301-308. 

20.  Loney  BR,  Frick  PJ,  Ellis  M,  et  al.  Intelligence, 
psychopathy,  and  antisocial  behavior.  / Psychopath 
Behav  Assess  1998;20:231-24 7. 

21.  Kazdin  AE.  Conduct  Disorders  in  Childhood  and 
Adolescence,  2nd  edition.  Thousand  Oaks,  Calif: 
Sage;  1995. 

22.  Conduct  Problems  Prevention  Research  Group.  A 
developmental  and  clinical  model  for  the 
prevention  of  conduct  disorder:  the  FAST  Track 
Program.  Dev  Psychopath  1992;4:509-527. 

23.  Henggeler  SW,  Borduin  CM.  Family  Therapy  and 
Beyond:  A Multisystemic  Approach  to  Treating  the 
Behavior  Problems  of  Children  and  Adolescents.  Pacific 
Grove,  Calif:  Brooks /Cole;  1990. 

24.  Henggeler  SW,  Schoenwald  SK,  Pickrel  SG. 
Multisystemic  therapy:  bridging  the  gap  between 
university-  and  community-based  treatment.  / 
Consult  Clin  Psychol  1995;63:709-718. 

25.  Center  for  the  Study  and  Prevention  of  Violence. 
Blueprint  for  Violence  Prevention.  Boulder,  Colo: 
University  of  Colorado;  1998. 


Adolescent  Violence 


Dr  Frick  is  Professor  of  Psychology  and  Director  of  the 
Applied  Developmental  Psychology  Program 
in  the  department  of  Psychology  at  the 
University  of  New  Orleans. 


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J La  State  Med  Soc  VOL  152  October  2000  503 


Adolescent  Violence 


The  Effects  of  Community  Violence  Exposure 

on  Louisiana’s  Children 

Nicole  F.  Lanclos,  MA;  Stewart  T.  Gordon,  MD;  and  Mary  Lou  Kelley,  PhD 


Substantial  evidence  exists  that  commu- 
nity violence  has  become  an  increasingly 
prevalent  part  of  life  for  many  youth.1  Re- 
cent studies  have  systematically  documented 
the  prevalence  and  effects  of  exposure  to  com- 
munity crime  and  violence  among  children,  es- 
pecially among  inner-city  youth.  Perry  and  col- 
leagues estimated  that  4 million  children  are  ex- 
posed to  a traumatic  event  each  year  including 
community  and  domestic  violence.2  In  a low-in- 
come neighborhood  in  New  Orleans,  a study 
found  that  51%  of  children  were  victims  of  and 
91%  were  witness  to  some  type  of  violence.3  Simi- 
larly, in  a survey  of  youth  in  Baton  Rouge,  Loui- 
siana, 28%  of  school-aged  children  endorsed 
hearing  gunshots  in  their  neighborhoods.4  Like- 
wise, high  rates  of  violence  exposure  are  reported 
in  studies  of  inner-city  children  conducted  in 


Chicago,  Los  Angeles,  and  Boston.5'7 

Pynoos  and  Nader  concluded  that  the  ef- 
fects of  repeated  exposure  to  violence  are  addi- 
tive with  continued  exposure  serving  to  exacer- 
bate symptomatology  caused  by  earlier  expo- 
sure.8 Youth  who  are  exposed  to  chronic  levels 
of  community  violence  are  at  significant  risk  for 
developing  a number  of  problems  including  de- 
pressive, anxiety,  conduct,  and  phobic  disorders. 
This  exposure  to  violence  affects  children's  abil- 
ity to  establish  solid  relationships  with  others, 
to  learn,  to  regulate  emotions  and  behavior,  and 
to  cope  with  stress. 

Growing  evidence  exists  suggesting  that 
young  children  who  witness  domestic  or  com- 
munity violence  can  experience  deleterious  de- 
velopmental consequences  even  when  the  child 
is  not  a direct  victim.  Some  often  erroneously 


504  J La  State  Med  Soc  VOL  152  October  2000 


Adolescent  Violence 


assume  that  infants  and  toddlers  do  not  remem- 
ber or  are  too  young  to  be  affected  by  exposure 
to  violence.9 Neurobiological  research  has  linked 
children's  early  experiences  to  the  organization 
of  the  brain  system. 

NEURODEVELOPMENTAL  EFFECTS 
OF  VIOLENCE  EXPOSURE 

The  human  brain  is  underdeveloped  at  birth,  yet 
reaches  80%  to  90%  of  its  adult  weight  by  age 
three.  According  to  Perry  and  Pollard,  "the  brain 
develops  in  a use-dependent  way,  mirroring  the 
pattern,  timing,  nature,  frequency,  and  quality 
of  the  experiences  of  the  young  child.  The  neu- 
ral systems  underlying  emotional,  behavioral, 
cognitive,  social,  and  physiological  functioning 
depend  upon  the  experiences  of  infancy  and 
childhood  to  organize  properly.  These  organiz- 
ing childhood  experiences  can  be  consistent,  nur- 
turing, structured,  and  enriched,  resulting  in 
flexible,  responsible,  empathic,  and  creative 
members  of  society.  However,  childhood  expe- 
riences can  be  neglectful,  chaotic,  violent,  and 
abusive,  resulting  in  impulsive,  aggressive,  re- 
morseless, and  anti-social  individuals.  Chaos, 
neglect,  pervasive  fear,  and  direct  violence  in 
early  childhood  result  in  disorganized  and  un- 
der-developed brains."10  A large  part  of  this  un- 
derdevelopment is  due  to  stress  and  increased 
levels  of  cortisol,  which  can  inhibit  brain  growth. 

In  addition  to  the  neurobiological  effects  of 
violence  exposure,  behavioral  manifestations  of 
trauma  can  be  present  in  infants  and  toddlers. 
Young  children  who  witness  domestic  or  com- 
munity violence  may  develop  impulsivity,  hy- 
peractivity, sleep  disturbances,  emotional  dis- 
tress, as  well  as  regressive  symptoms  such  as 
dependence,  separation  anxiety,  bed-wetting, 
and  decreased  verbalizations.2,11'12  Young 
children's  exposure  to  violence  interferes  with 
their  development  of  trust  and  autonomy  thus 
thwarting  their  exploratory  behaviors.  Their 
natural  curiosity  and  exploration  of  the  world 
may  be  diminished  when  their  world  is  a dan- 
gerous and  unpredictable  place.13  Although  the 
research  is  limited  on  posttraumatic  reactions  in 
infants  and  young  children,  it  is  recognized  that 


infants  and  toddlers  who  witness  violence  may 
show  posttraumatic  symptomatology.  The  be- 
havioral presentation  of  the  posttraumatic  reac- 
tion in  very  young  children  is  similar  to  the  post- 
traumatic stress  disorder  in  adults  including 
avoiding,  numbing  of  responsiveness,  increased 
arousal,  and  repeated  re-experiencing  of  the 
traumatic  event.14 

Community  violence  exposure  continues  to 
have  adverse  effects  on  children  beyond  the 
early  childhood  years.  Recent  empirical  studies 
have  examined  stress  symptoms  in  children  and 
adolescents  in  communities  characterized  by 
violence  and  crime.  In  general,  findings  suggest 
that  children  exposed  to  violence  are  more  likely 
to  display  higher  rates  of  internalizing  and  ex- 
ternalizing psychopathology  compared  to  their 
non-exposed  peers.  In  a sample  of  3700  high 
school  students.  Singer,  Anglin,  Song,  and 
Lunghofer  demonstrated  a significant,  positive 
relationship  between  exposure  to  violence  and 
depression,  anger,  anxiety,  dissociation,  and 
posttraumatic  stress.15  Similarly,  Gorman-Smith 
and  Tolan  demonstrated  a relationship  between 
exposure  to  community  violence  and  symptoms 
of  depression,  anxiety,  and  aggressive  behaviors 
in  children.16  Additionally,  adolescents  who  have 
witnessed  violence  may  engage  in  self-destruc- 
tive behaviors  such  as  promiscuity,  substance 
abuse,  and  other  aggressive  acts.1" 

Examining  the  interpersonal  effects  of  ex- 
posure to  community  violence  on  children, 
Cooley-Quille,  Turner,  and  Beidel  found  that 
children  exposed  to  higher  levels  of  community 
violence  demonstrated  increased  general  activ- 
ity and  restlessness  as  well  as  impaired  social 
and  behavioral  functioning.18  Higher  community 
violence  exposure  was  inversely  correlated  with 
social  competence  in  interpersonal  functioning 
according  to  parental  report.  Similarly,  in  a lon- 
gitudinal study  with  elementary  school  students, 
exposure  to  chronic  community  violence  pre- 
dicted peer-rated  aggression.19  A cross-sectional 
examination  of  adolescents  in  Atlanta,  Georgia 
indicated  that  previous  exposure  to  violence  and 
victimization  was  the  strongest  predictor  of  use 
of  violence  by  those  teens.20 

J La  State  Med  Soc  VOL  152  October  2000  505 


Adolescent  Violence 


ACCUMULATION  OF  RISK  FACTORS  FOR 
CHILDREN  IN  VIOLENT  COMMUNITIES 

In  addition  to  the  chronic  direct  effects  of  vio- 
lence exposure,  children  living  in  violent  neigh- 
borhoods often  are  plagued  by  additional  ad- 
versities. For  children,  the  experience  of  living 
in  a violent  community  often  occurs  within  a 
larger  framework  of  stressors  and  adversities. 
Risk  factors  that  exacerbate  the  effects  of  violence 
exposure  include  substance  abuse,  unemploy- 
ment, low  socioeconomic  status,  poverty,  poor 
nutrition,  and  lack  of  adequate  medical  care.21 
Louisiana,  unfortunately,  has  the  highest  pov- 
erty rate  in  the  United  States  with  1 in  3 chil- 
dren living  in  poverty  and  1 in  5 children  living 
in  extreme  poverty  (annual  income  for  a family 
of  4 = $8,200).  Additional  familial  adversities 
include  absent  fathers,  instability  and  conflict, 
and  lower  levels  of  parental  education.2223  In 
addition  to  the  high  levels  of  chronic  commu- 
nity violence,  such  risk  factors  often  are  present 
in  the  lives  of  inner-city  children  and  may  exac- 
erbate poor  developmental  outcome. 

The  presence  of  these  chronic  adversities  can 
negatively  affect  parenting  and  caregiving.  The 
most  important  protective  factor  for  children  be- 
ing reared  with  exposure  to  violence  is  the  pres- 
ence of  a stable,  protective,  nurturing  adult,  typi- 
cally a parent.2425  However,  parents  of  children 
who  are  exposed  to  violence  often  suffer  from 
feelings  of  helplessness  and  guilt  about  their  in- 
ability to  protect  their  children  from  community 
violence.26  In  response  to  living  in  violent  neigh- 
borhoods, parents  may  become  overprotective 
and  may  discourage  autonomy  and  exploration. 
Because  of  the  dangerousness  of  the  neighbor- 
hoods, parents  may  attempt  to  protect  their  chil- 
dren by  keeping  them  indoors.  When  parents 
adopt  such  a protective  style  and  restrict  outdoor 
play,  they  deprive  their  children  of  important 
social  and  emotional  experiences.  Hence,  social 
isolation,  for  both  the  child  and  parent,  may  be 
an  undesired  outcome  of  living  in  a violent  neigh- 
borhood. Maternal  isolation  results  in  reduced 
opportunities  for  contact  with  other  parents  that 
typically  serve  as  a source  of  information  about 
parenting  as  well  as  social  support.27'29 


In  addition  to  restrictive  parenting  styles,  par- 
ents exposed  to  violence  may  become  depressed 
and  less  able  to  respond  to  their  children's  needs. 
Depressed  parents  have  been  found  to  talk  less 
to  their  infants,  display  less  positive  physical  af- 
fection, and  show  fewer  positive  facial  expres- 
sions to  their  children.30  Additionally,  maternal 
depression  has  been  associated  with  negative 
parenting  behavior  and  undesirable  parenting 
practices  such  as  unresponsiveness,  inattentive- 
ness, inconsistent,  and  inadequate  discipline.31 
The  combination  of  depression  in  the  mother 
coupled  with  the  above  risk  factors  increases  the 
risk  of  poor  developmental  outcome  for  children 
living  in  violent  communities. 

PROTECTIVE  FACTORS  AND  RESILIENCE 

Recently,  researchers  have  begun  to  examine  fac- 
tors which  promote  resilience  to  community  vio- 
lence. Resiliency  generally  refers  to  the  ability  of 
some  children  to  have  good  outcomes  despite 
risk,  to  have  the  ability  to  recover  from  trauma, 
and  to  sustain  competence  under  stress.32  Factors 
found  to  promote  resilience  that  have  been  con- 
sistently supported  by  the  literature  include  a 
child's  internal  resources,  family  cohesion  and  a 
caring  adult,  and  support  within  the  community.33 

Crucial  to  the  emergence  of  a resilient  child 
growing  up  amidst  community  violence  is  the 
presence  of  a relationship  with  a protective,  car- 
ing parent  or  caretaker.34  For  example,  children 
who  perceived  greater  familial  support  showed 
less  anxiety  even  when  exposed  to  higher  levels 
of  community  violence.24  In  a study  in  Colum- 
bia, most  resilient,  young  adults  who  grew  up 
in  neighborhoods  characterized  by  high  levels 
of  violence  perceived  their  mothers  as  stronger 
and  more  supportive  with  an  emphasis  on  teach- 
ing the  value  of  education  and  work  compared 
to  the  mothers  of  persistent  and  temporary  of- 
fenders.35 Additional  parental  characteristics 
such  as  maternal  education  and  competence  are 
associated  with  better  outcomes  in  children  and 
can  serve  to  buffer  the  deleterious  effects  of  vio- 
lent communities.36 

Various  factors  within  children  are  associ- 
ated positively  with  their  ability  to  overcome  ad- 


506  J La  State  Med  Soc  VOL  152  October  2000 


Adolescent  Violence 


versity.  As  early  as  infancy,  temperament  and 
cognitive  factors  that  enable  children  to  use  their 
own  internal  resources  promote  resiliency  in 
children  in  disadvantaged  settings.  The  most  im- 
portant individual  characteristic  that  is  associ- 
ated positively  with  the  ability  to  overcome  ad- 
versity is  average  to  above-average  intelligence, 
especially  verbal  abilities  and  problem  solving 
skills.  Furthermore,  children  who  are  engaging, 
sociable,  self-reliant,  and  confident  are  more  re- 
silient when  faced  with  adversity.3237 

Finally,  resilient  children  living  in  violent 
neighborhoods  are  likely  to  obtain  significant 
support  from  community  resources  including 
friends,  schools,  and  churches.  Even  when  the 
location  of  the  school  is  in  a violent  area,  a posi- 
tive school  climate  can  provide  structure  and  a 
nurturing,  predictable  environment.  Teachers 
and  daycare  providers  can  serve  as  positive  role 
models  and  provide  emotional  support  to  chil- 
dren. Similarly,  churches  often  are  important 
sources  of  social  support  to  children  and  fami- 
lies exposed  to  community  violence.  Social  net- 
works provided  by  such  community  organiza- 
tions foster  prosocial  skills  in  children  and  can 
increase  opportunities  for  positive  peer  and 
adult  relationships  thereby  mediating  the  effects 
of  community  violence  on  children.32 

CONCLUSION 

Thousands  of  Louisiana's  children  are  growing 
up  in  neighborhoods  characterized  by  chronic 
levels  of  violence.  Continuous  exposure  to  such 
violence  can  have  deleterious  effects  on 
children's  social,  emotional,  and  behavioral 
functioning.  Fortunately,  children  are  resilient. 
However,  when  their  resilience  fails  them  and 
they  begin  to  show  the  emotional  effects  of  ex- 
posure to  community  violence,  it  is  incumbent 
upon  their  parents,  physicians,  schoolteachers, 
and  clinicians  to  recognize  symptoms  of  psycho- 
logical trauma.  Hence,  it  is  imperative  that  cli- 
nicians and  physicians  inquire  about  violence 
exposure,  identify  high-risk  situations,  and  es- 
tablish and  implement  means  of  early  detection 
and  intervention. 


REFERENCES 

1 . American  Psychological  Association  Commission 
on  Violence  and  Youth.  Violence  and  Youth: 
Psychology's  Response.  Washington,  DC:  Public 
Interest  Directorate,  American  Psychological 
Association;  1993. 

2.  Perry  BD,  Pollard  RA,  Blakley  TL,  et  al.  Childhood 
trauma,  the  neurobiology  of  adaptation  and  "use 
dependent"  development  of  the  brain:  How 
"states"  become  "traits".  Infant  Mental  Health 
Journal  1995;16:271-291. 

3.  Osofsky  JD,  Wewers  S,  Harm  DM,  et  al.  Chronic 
community  violence:  what  is  happening  to  our 
children?  Psychiatry  1993;56:36-45. 

4.  Flowers  AL,  Hastings  TL,  Kelley  ML. 
Development  of  a screening  instrument  for 
exposure  to  violence  in  children:  The  KID-SAVE.  / 
Psychopathol  Behav  Assess  2000;22. 

5.  Garbarino  J,  Dubrow  N,  Kostelny  K,  et  al.  Children 
in  DangeriCoping  with  the  Consequences  of 
Community  Violence.  San  Francisco:  Jossey  Bass 
Publishers;  1992. 

6.  Pynoos  RS,  Eth  S.  Witness  to  violence:  the  child 
interview.  J Am  Acad  Child  Psychiat  1986;  25:306- 
319. 

7.  Taylor  L,  Zuckerman  B,  Harik  V,  et  al.  Witnessing 
violence  by  young  children  and  their  mothers.  / 
Develop  Behav  Pediatr  1994;15:120-123. 

8.  Pynoos  R,  Nader  K.  Psychological  first  aid  and 
treatment  approach  to  children  exposed  to 
community  violence:  research  implications.  / 
Traum  Stress  1988;l,445-473. 

9.  Osofsky  JD.  The  impact  of  violence  on  children. 
Future  of  Children  1999;9:33-49. 

10.  Perry  BD,  Pollard  R.  Homeostasis,  stress,  trauma, 
and  adaptation:  a neurodevelopmental  view  of 
childhood  trauma.  Child  Aaoles  Psychiat  Clin  North 
Am  1998;7:33-51. 

11.  Osofsky  JD.  The  effects  of  exposure  to  violence  on 
young  children.  Am  Psychol  1995;50:782-788. 

12.  Zeanah  CH,  Scheeringa  MS.  The  experience  and 
effects  of  violence  in  infancy.  In:  Osofsky  JD 
(editor).  Children  in  a Violent  Society.  New  York: 
Guilford  Press;  1997:97-123. 

13.  Groves  BM.  Growing  up  in  a violent  world:  the 
impact  of  family  and  community  violence  on 
young  children  and  their  families.  In:  Erwin  EJ 
(editor).  Putting  Children  First:  Visions  for  a Brighter 
Future  for  Young  Children  and  Their  Families.  Boston: 
Brookes;  1996:31-52. 

14.  Scheeringa  MS,  Zeanah  CH,  Drell  MJ,  et  al.  Two 
approaches  to  the  diagnosis  of  post-traumatic 
stress  disorder  in  infancy  and  early  childhood.  / 


J La  State  Med  Soc  VOL  152  October  2000  507 


Adolescent  Violence 


Am  Acad  Child  Adoles  Psychiat  1995;34:191-200. 

15.  Singer  MI,  Anglin  TM,  Song  LY,  et  al.  Adolescents' 
exposure  to  violence  and  associated  symptoms  of 
psychological  trauma.  JAMA  1995;273:477-482. 

16.  Gorman-Smith  D,  Tolan  P.  The  role  of  exposure  to 
community  violence  and  developmental  problems 
among  inner-city  youth.  Develop  Psychopathol 
1998;10:101-116. 

17.  Jenkins  EJ,  Bell  CC.  Exposure  and  response  to 
community  violence  among  children  and 
adolescents.  In:  Osofsky  JD  (editor).  Children  in  a 
Violent  Society.  New  York:  Guilford  Press;  1997:9- 
31. 

18.  Cooley-Quille  MR,  Turner  SM,  Beidel  DC. 
Emotional  impact  of  children's  exposure  to 
community  violence:  a preliminary  study.  J Am 
Acad  Child  Adoles  Psychiat  1995;34:1362-1368. 

19.  Attar  BK,  Guerra  NG.  The  effects  of  cumulative 
violence  exposure  on  children  living  in  violent 
neighborhoods.  Paper  presented  at  the  American 
Psychological  Society  Convention,  Washington, 
DC,  June  1994. 

20.  DuRant  RH,  Cadenhead  C,  Pendergrast  RA,  et  al. 
Factors  associated  with  the  use  of  violence  among 
urban  black  adolescents.  Am  J Public  Health  1994; 
84:612-617. 

21 . Bradley  RH,  Whiteside  L,  Mundfrom  DJ,  et  al.  Early 
indications  of  resilience  and  their  relation  to 
experiences  in  the  home  environments  of  low 
birthweight,  premature  children  living  in  poverty. 
Child  Develop  1994;65:346-360. 

22.  Garmezy  N.  Children  in  poverty:  resilience  despite 
risk.  Psychiatry  1993;56:127-136. 

23.  Kotlowitz  A.  There  are  No  Children  Here.  New  York: 
Doubleday;  1991. 

24.  Hill  HM,  Levermore  M,  Twaite  J,  et  al.  Exposure  to 
community  violence  and  social  support  as 
predictors  of  anxiety  and  social  and  emotional 
behavior  among  African  American  children.  J Child 
Family  Studies  1996;5:399-414. 

25.  Richters  JE,  Martinez  P.  The  NIMH  community 
violence  project:  children  as  victims  of  and  witness 
to  violence.  Psychiatry  1993;56:7-21. 

26.  Osofsky  JD,  Jackson  B.  Parenting  in  violent 
environments.  In:  Osofsky  JD,  Jackson  BR  (editors). 
Caring  for  Infants  and  Toddlers  in  Violent 
Environments:  Hurt,  Healing,  and  Hope.  Arlington, 
Va:  Zero  to  Three /National  Center  for  Clinical 
Infant  Programs;  1994:8-12. 

27.  Groves  BM,  Zuckerman  B.  Interventions  with 
parents  and  caregivers  of  children  who  are  exposed 
to  violence.  In:  Osofsky  JD  (editor).  Children  in  a 
Violent  Society.  New  York:  Guilford  Press;  1997:183- 
201. 


28.  Vig  S.  Young  children's  exposure  to  community 
violence.  J Early  lnterven  1996;20:319-328. 

29.  Gaensbauer  TJ,  Siegel  CH.  Therapeutic  approaches 
to  posttraumatic  stress  disorder  in  infants  and 
toddlers.  Infant  Mental  Health  J 1995;  16:292-305. 

30.  Murray  L,  Cooper  PJ.  The  role  of  infant  and 
maternal  factors  in  postpartum  depression,  mother- 
infant  interactions,  and  infant  outcome.  In:  Murray 
L,  Cooper  PJ  (editors).  Postpartum  Depression  and 
Child  Development.  New  York:  Guilford  Press;  1997: 
111-135. 

31.  Gelfand  DM,  Teti  DM.  The  effects  of  maternal 
depression  on  children.  Clin  Psychol  Rev 
1990;10:329-353. 

32.  Werner  EE.  Protective  factors  and  individual 
resilience.  In:  Shonkoff  JP,  Meisels  SJ  (editors). 
Handbook  of  Early  Childhood  Intervention.  UK: 
Cambridge  University  Press;  2000:115-132. 

33.  Garmezy  N.  Stressors  of  childhood.  In:  Garmezy 
N,  Rutter  M (editors).  Stress,  Coping,  and 
Development  in  Children.  New  York:  McGraw-Hill; 
1983:43-84. 

34.  Masten  AS,  Hubbard  JJ,  Gest  SD,  et  al.  Competence 
in  the  context  of  adversity:  pathways  to  resilience 
and  maladaptation  from  childhood  to  late 
adolescence.  Develop  Psychopathol  1999;11:143-169. 

35.  Klevens  J,  Roca  J.  Nonviolent  youth  in  a violent 
society:  resilience  and  vulnerability  in  the  Country 
of  Colombia.  Violence  and  Victims  1999;14:311-322. 

36.  Cicchetti  D,  Lynch  M.  Toward  an  ecological/ 
transactional  model  of  community  violence  and 
child  maltreatment:  consequences  for  children's 
development.  Psychiatry  1993;56:96-118. 

37.  Marans  S,  Cohen  D.  Children  and  inner  city 
violence:  strategies  for  intervention.  In:  Leavitt  LA, 
Fox  NA  (editors).  Psychological  Effects  of  War  and 
Violence  on  Children.  Hillsdale,  NJ:  Lawrence 
Erlbaum  Associates;  1993:281-302. 


Ms  Lanclos  is  a PhD  graduate  student  in  the  Eouisiana 
State  University  Clinical  Psychology  Program  at 
Louisiana  State  University  Health  Sciences  Center! 
Earl  K Long  Medical  Center  in  Baton  Rouge,  Eouisiana. 

Dr  Gordon  is  a pediatrician  and  Chief  of  Pediatrics  at 
Eouisiana  State  University  Health  Sciences  Center! 
Earl  K Long  Medical  Center  in  Baton  Rouge,  Eouisiana. 

Dr  Kelley  is  head  of  the  Clinical  Psychology  Program  at 
Eouisiana  State  University  Health  Sciences  Center! 
Earl  K Long  Medical  Center  in  Baton  Rouge,  Eouisiana. 


508  J La  State  Med  Soc  VOL  152  October  2000 


Adolescent  Violence 


Violence  Prevention:  Myth  or  Reality? 

Pat  Melton,  LCSW 


Newspapers  and  television  daily  attest  to  the  fact  that  violence  is  a pervasive  element  in  our 
society,  especially  among  our  youth.  We  have  come  to  a point  in  this  nation  where  we  see 
violence  everywhere.  It  is  on  the  streets,  in  the  workplace,  and  especially  in  the  schools.  How 
did  this  happen  to  our  society?  Is  this  unrivaled  period  of  juvenile  violent  crime  a new  phe- 
nomenon? Our  society  demands  that  children  have  a safe  environment  in  which  to  learn  and 
grow,  yet  continued  reports  of  youth  violence  indicates  that  our  efforts  have  not  been  success- 
ful. Is  violence  prevention  a myth  or  reality?  Since  children  are  our  future,  how  can  we  pro- 
vide them  with  the  skills  that  will  afford  them  the  opportunity  to  become  productive  mem- 
bers of  society? 


It  is  painfully  evident  that  our  nation  is  ex- 
periencing an  unrivaled  period  of  juvenile 
violent  crime  and  that  the  scope  of  the  prob- 
lem is  much  broader  than  statistics  reveal.  Juve- 
nile crime  is  not  a new  phenomenon,  but  what 
is  new  is  the  possibility  of  how  disagreements 
between  youth  will  be  settled.  A major  differ- 
ence between  youth  violence  now  and  in  the  past 
is  the  presence  and  use  of  weapons,  especially 
guns.  Today  it  is  more  likely  that  a disagreement 
among  youth  will  be  settled  with  some  type  of 
weapon  rather  than  an  old-fashioned  fist  fight. 
In  fact,  fifty  years  ago,  the  main  disciplinary 


problems  in  the  classroom  were  as  minor  as  run- 
ning in  halls,  talking  out  of  turn,  and  chewing 
gum.  However,  problems  in  today's  schools 
range  from  physical  and  verbal  violence,  inci- 
vility, and  in  some  schools,  drug  abuse,  robbery, 
assault,  and  murder.  According  to  the  Depart- 
ment of  Justice,  all  schools  have  experienced  an 
increase  in  school  violence.  School  violence  in 
all  its  forms  — threats,  fistfights,  weapons,  bul- 
lying, pushing,  shoving,  and  other  youth  mis- 
conduct — is  unacceptable.  Violence  in  some 
schools  may  be  a minor  issue  while  for  other 
schools  it  may  be  a daily  presence.  While  the 


J La  State  Med  Soc  VOL  152  October  2000  509 


Adolescent  Violence 


most  extreme  forms  of  violence  are  the  excep- 
tion, violence  in  all  its  forms  have  a negative 
impact  on  our  youth  and  the  broader  commu- 
nity. Children,  teachers  and  staff,  and  commu- 
nities deserve  safe  schools  in  which  to  learn,  to 
work,  and  to  help  keep  neighborhoods  safe. 

It  is  painfully  evident  that  we  are  experienc- 
ing an  unrivaled  period  of  juvenile  violent  crime 
that  impacts  the  very  core  of  our  society.  Chil- 
dren are  not  only  victims  of  crimes  but  are  also 
victimizers.  In  light  of  the  increasing  incidents 
of  youth  violence  in  this  nation,  we  now  regard 
youth  violence  as  one  of  American  society's  most 
pressing  concerns.  In  spite  of  this  fact,  it  is  im- 
portant to  remember  that  the  vast  majority  of 
today's  youth  are  not  violent  nor  have  they  com- 
mitted any  acts  of  violence.  The  tragic  violent 
incidents  that  occurred  in  the  schools  during  the 
1998-99  and  1999-2000  school  years  have  cer- 
tainly made  it  clear  that  the  American  public 
needs  to  focus  on  school  crime  and  safety.  Al- 
though it  is  apparent  that  the  majority  of 
America's  schools  are  safe,  too  many  children 
face  a frightening  reality  every  time  they  enter 
school.1  The  Executive  Summary:  Indicators  of 
School  Crime  Safety  1998  reported  that  students 
ages  12  through  18  were  victims  of  about  255,000 
incidents  of  nonfatal  serious  violent  crime  at 
school  and  671,000  incidents  away  from  school.2 
According  to  the  Bureau  of  Justice  Statistics,  the 
fear  of  attack  at  school  is  so  prevalent  that  one 
in  fifteen  students  would  avoid  certain  places 
at  school  they  felt  were  not  safe.3  The  National 
School  Safety  Center  reports  that  nearly  three 
million  violent  crimes  and  thefts  occur  each  year 
on  school  grounds  and  that  every  day  160,000 
American  children  miss  school  fearing  attack  or 
intimidation  by  other  students.3 

The  following  facts  further  illustrate  the 
problem  of  youth  violence  in  the  school  setting:1 

1.  25%  to  30%  of  school-aged  children  today 
exhibit  behavioral  problems. 

2.  Students  are  more  fearful  at  school  today 
than  in  the  past. 

3.  40%  of  students  feel  the  threat  of  violence  is 

always  there  and  do  not  like  it. 


4.  900  teachers  are  threatened  and  over  2,000 
students  and  nearly  40  teachers  are  physi- 
cally attacked  on  school  grounds  every  hour 
of  each  school  day  each  year. 

5.  The  most  common  types  of  violence  are  fist 
fights,  bullying,  and  shoving  matches. 

6.  1 out  of  3 public  school  teachers  will  be  ver- 
bally abused. 

7.  8%  of  teachers  in  public  schools  will  be  physi- 
cally threatened. 

8.  1 out  of  4 children  are  bullied. 

9.  Children  and  youth  today  are  the  victims  of 
more  crime  than  any  other  age  group  in  the 
United  States. 

10.  School  violence  has  a physical,  psychologi- 
cal, and  emotional  effect  on  students  and 
staff. 

11.  The  threat  of  all  kinds  of  violence  can  keep 
kids  away  from  school  and  keep  them  in  fear 
every  day. 

Since  the  tragedy  at  Columbine  High  School, 
April  20,  1998,  more  than  5,000  bomb  threats 
have  been  made  at  schools.  In  addition,  more 
than  1 million  acts  of  violence,  from  fistfights  to 
murders  to  suicides,  occur  every  year.4  Every 
day,  13  students  on  average  are  suspended,  ex- 
pelled or  arrested  for  bringing  a firearm  to 
school.4  In  April  2000,  the  USA  Today  "Threat  of 
Violence  Throughout  School  Year"  reported  the 
following  listing  of  incidents  of  school  violence 
in  the  1999-2000  school  year:4  ("Copyright  2000, 
USA  TODAY.  Reprinted  with  permission.") 

INCIDENTS  AT  US  SCHOOLS 
IN  1999-2000  SCHOOL  YEAR 

August 

25:  Monticello,  GA- A student,  16,  commits  sui- 
cide in  a pickup  in  a high  school  parking  lot. 

September 

7 : Plano,  Texas  - A student,  1 6,  commits  suicide 
with  a gun  in  a high  school  restroom. 

7:  San  Francisco  - An  8th  grade  boy  shoves  an 
electric  stun  gun  at  a classmate,  shocking  the 
boy  in  his  chest. 

9:  San  Jose,  CA  - A student,  16,  commits  sui- 


510  J La  State  Med  Soc  VOL  1 52  October  2000 


Adolescent  Violence 


cide  with  a gun  in  a high  school  restroom. 

22:  Tampa  - Five  children  are  robbed  at  gunpoint 
of  their  shirts  and  shoes  while  waiting  for 
the  bus  to  school.  Two  classmates  are  ar- 
rested. 

28:  Tampa  - A fifth-grader,  10,  is  shot  in  the  head 
outside  her  elementary  school.  She  survives. 

October 

4:  Philadelphia  - A vice-principal  is  shot  in  the 
leg  while  taking  a gun  from  a student. 

6:  Parlier,  CA  - An  18-year-old  drives  a pickup 
onto  a sidewalk  outside  a high  school,  kill- 
ing a student,  17,  who  had  reportedly  been 
involved  in  an  argument  with  the  driver  ear- 
lier in  the  afternoon. 

6:  Lecanto,  Florida  - A lOth-grader  brandishes 
a knife,  claims  to  have  two  bombs  and  holds 
a dozen  classmates  and  his  English  teacher 
at  bay  before  surrendering. 

11:  Las  Vegas  - Two  students  are  shot  and 
wounded  outside  their  high  school  in  a sus- 
pected gang-related  incident. 

12:  Arlington,  VA  - Two  fifth-graders,  both  10, 
are  accused  of  pouring  antibacterial  soap  in 
their  teacher's  drinking  water.  The  teacher 
is  not  hurt. 

21:  Pacoima,  CA  - A student,  17,  is  shot  outside 
a high  school  child-care  center. 

26:  Philadelphia  - A student,  16,  is  shot  to  death 
in  front  of  a high  school. 

26:  Houston  - A boy,  13,  is  stabbed  in  the  head 
with  a screwdriver  during  an  alleged  gang- 
related  fight  at  his  middle  school.  He  later 
dies  from  the  injuries. 

26:  Omaha  - A student,  17,  dies  after  hitting  his 
head  on  the  floor  during  a fight  in  the  high 
school  cafeteria. 

November 

3:  Oklahoma  City  - A boy,  4,  is  suspended  for  a 
year  for  taking  to  school  a loaded  handgun 
he  found  at  home. 

3:  Boston  - A student,  17,  is  shot  in  the  face  out- 
side his  high  school  during  a fight. 

4:  Perris,  CA  - Two  boys,  both  11,  are  accused 
of  confronting  a schoolmate,  pulling  out  a 
handgun  and  pulling  the  trigger.  The  gun 


does  not  fire. 

5:  Denver  - A middle  school  student,  13,  is  ar- 
rested after  telling  classmates  he  is  gather- 
ing guns  to  shoot  students. 

5:  Cleveland  - Five  students  are  arrested  for  al- 
legedly plotting  a Columbine-style  bomb 
and  shooting  rampage  at  their  school. 

9:  Menifee,  CA  - A lOth-grader  is  accused  of 
threatening  to  blow  up  his  high  school  and 
looking  for  bomb-making  instructions  on  the 
Internet. 

12:  Lakeland,  Florida  - A 7th-grader,  12,  tries  to 
choke  a teacher  who  confiscated  his 
Pokemon  trading  cards. 

16:  New  York  - A school  security  guard,  25,  dies 
of  a heart  attack  while  trying  to  break  up  a 
fight. 

17:  Dickinson,  Texas  - A 9th-grader,  15,  is  shot 
in  the  face  when  another  student,  16,  tries  to 
unload  a handgun  in  the  restroom. 

18:  Denver  - A student,  15,  shoots  himself  out- 
side his  high  school  in  an  apparent  suicide 
attempt,  then  stumbles  back  into  the  school, 
bleeding,  and  seeking  help. 

19:  Deming,  N.M.  - A girl,  13,  dies  after  being 
shot  in  the  back  of  the  head  while  standing 
in  the  lobby  of  her  middle  school.  A boy,  13, 
is  arrested. 

19:  Palmdale,  CA- Aboy,  13,  dies  of  injuries  from 
a punch  thrown  by  a classmate,  14,  during  a 
fistfight. 

22:  Augusta,  GA  - An  8th-grade  boy,  14,  is  ar- 
rested and  accused  of  stabbing  his  teacher 
in  the  face,  neck,  and  back  with  a pair  of  scis- 
sors. The  teacher  is  injured  critically. 

22:  Wilmington,  N.C.  - Classes  are  evacuated  af- 
ter two  high  school  students  leave  bomb 
threats  and  plant  devices  made  to  look  like 
bombs  throughout  the  school.  Both  boys  are 
arrested. 

30:  Haines  City,  Florida  - A girl,  17,  is  expelled 
after  authorities  discover  a notebook  filled 
with  descriptions  of  killing  people  and 
bombing  her  high  school. 

30:  Cooper  City,  Florida  - A boy,  10,  is  accused 
of  groping  and  threatening  two  boys  in  his 
class  for  more  than  a year. 


J La  State  Med  Soc  VOL  152  October  2000  511 


Adolescent  Violence 


December 

2:  Louisville  - A high  school  boy  is  slashed  in 
the  head  and  neck  with  a razor  during  a fight 
on  the  school  bus. 

5:  Cherokee  County,  GA  - A high  school  senior 
is  arrested  and  accused  of  threatening  to  kill 
a teacher  who  had  suspended  the  student  for 
bringing  two  knives  to  class. 

6:  Fort  Worth  - Two  high  school  students  are 
suspended  for  allegedly  tying  a noose 
around  the  neck  of  a student  with  cerebral 
palsy. 

6:  Fort  Gibson,  Oklahoma  - Four  middle  school 
students  are  shot  and  wounded  when  some- 
one peppers  the  school  with  9mm  gunfire. 
Police  arrest  a male  student,  13. 

7 : Santa  Fe  - Two  high  school  seniors  are  arrested 
and  accused  of  beating  and  kicking  a 15-year- 
old  classmate  unconscious  in  the  school  caf- 
eteria. 

7:  Rochester,  NY  - A freshman,  14,  is  arrested 
for  allegedly  bringing  a stolen  handgun  to 
high  school  and  attempting  to  sell  it  to  an- 
other student. 

7 : Manassas,  VA  - A junior  high  school  teacher 
is  arrested  and  charged  with  assault  for  al- 
legedly grabbing  a student,  13,  by  the  arms 
and  backpack  and  shoving  him  against  a 
bank  of  lockers  after  an  argument. 

9:  Indianapolis  - Two  high  school  boys  are  sus- 
pended for  leaving  a note  that  said  the  school 
"will  die  on  12/10/99",  and  for  scattering 
bullets  through  the  school. 

10:  Portland,  Oregon  - More  than  half  the  stu- 
dent body  of  a high  school  skips  school  after 
bathroom  graffiti  is  found  that  says,  "If  you 
think  Columbine  was  bad,  wait  until  Dec. 
10,  1999."  No  violence  is  reported. 

15:  Fullerton,  CA  - A boy,  14,  is  suspended  for 
creating  an  elaborate  plot  - including  school 
diagrams  and  escape  routes  - to  duplicate  the 
Columbine  slayings  at  his  junior  high  school. 

15:  New  Port  Richey,  Florida  - A high  school  boy, 
17,  is  caught  on  campus  with  a switchblade, 
which  he  says  he  needs  for  protection  from 
other  students. 

15:  Miami  - A boy,  14,  walks  into  his  high  school 


biology  class  with  two  guns.  He  orders  the 
teacher  out  and  holds  students  captive  be- 
fore surrendering  his  weapons  to  another 
teacher. 

16:  Paterson,  N.J.  - Nine  students  are  arrested 
after  a racially  tinged  brawl  between  Afri- 
can-American and  Dominican  students 
leaves  eight  children  and  a teacher  hurt. 

17:  Upland,  CA  - A boy,  12,  is  suspended  after 
drawing  a map  of  where  he  said  bombs 
would  be  placed  and  compiling  a list  of  stu- 
dents he  wanted  to  kill. 

17:  New  Britain,  Connecticut  - Two  high  school 
sophomore  girls  are  arrested  and  accused  of 
pouring  a toxic  cleaning  fluid  into  their 
teacher's  coffee  when  she  briefly  left  the 
classroom.  The  teacher  did  not  drink  the 
tainted  coffee. 

22:  Poquoson,  Virginia  - A senior,  18,  is  sus- 
pended after  police  discover  a map  of  where 
he  planned  to  set  bombs  throughout  his 
school.  They  also  find  bomb-making  mate- 
rials at  his  home. 

January 

3:  Boston  - A boy,  15,  brings  a loaded  gun  to 
school.  Before  he  is  caught,  he  leads  officers 
on  a chase  through  the  school  and  into  the 
street. 

5:  Cedar  Park,  Texas  - A female  sixth-grade  stu- 
dent, 12,  hangs  herself  in  a middle  school 
restroom. 

5:  Minneapolis  - A 13-year-old  girl  is  raped  in 
a stairwell  after  finishing  gymnastics  prac- 
tice at  her  high  school.  A student,  16,  is  ar- 
rested and  charged  with  rape. 

6:  Norman,  Oklahoma  - Police  arrest  two  high 
school  boys  after  discovering  a shotgun  and 
hunting  bow  in  their  car  in  the  school  park- 
ing lot. 

10:  Garden  Grove,  CA  - Nearly  half  of  the  chil- 
dren at  the  1,600  student  high  school  are  kept 
home  after  authorities  discover  a note  prom- 
ising a Columbine-like-massacre.  No  vio- 
lence is  reported. 

10:  Blanco,  Texas  - Police  arrest  a student  and 
three  other  teenagers  after  discovering  a pipe 
bomb  in  a school  restroom. 


512  J La  State  Med  Soc  VOL  152  October  2000 


Adolescent  Violence 


12:  Anchorage  - A boy,  16,  is  accused  of  pulling 
a gun  and  firing  twice  at  another  student. 
Both  shots  miss;  one  bullet  pierces  the  school 
gym  wall. 

13:  Albuquerque  - Several  students  fire  shots 
into  a crowded  school  parking  lot  after  a 
fight.  No  one  is  hurt.  Hours  later,  two  stu- 
dents are  arrested  and  accused  of  assaulting 
a police  officer  who  tried  to  break  up  another 
brawl. 

14:  Buffalo  - A girl,  13,  is  hospitalized  with  a frac- 
tured skull  and  brain  injuries  after  another 
girl  in  the  school  throws  her  to  the  ground 
during  a fight. 

19:  New  Port  Richey,  Florida  - A boy,  16,  is  killed 
when  a classmate  accidentally  fires  a hand- 
gun as  the  two  sit  in  a car  in  the  school  park- 
ing lot. 

19:  Prairie  Village,  Kansas  - Police  arrest  a boy, 
13,  who  they  say  tried  to  skip  school  by  phon- 
ing in  nine  bomb  threats.  The  threats 
prompted  a school  lockdown  and  police 
sweeps  of  the  school. 

20:  Hernando,  Tennessee  - A high  school  senior 
is  arrested  after  school  officials  find  brass 
knuckles,  a metal  pipe  and  a box  cutter  in 
his  car  in  the  school  parking  lot.  The  boy  says 
he  needs  the  items  for  protection. 

21:  Asheville,  N.C.  - A bullet  from  a high-pow- 
ered rifle  pierces  the  high  school  gym  dur- 
ing a boys7  varsity  basketball  team  practice. 
No  one  is  injured;  police  arrest  a 16-year-old 
dropout  from  the  school  in  the  shooting. 

21:  Jupiter,  Florida  - Almost  40%  of  the  1,800  stu- 
dents of  a local  high  school  are  kept  home 
after  a rumor  circulates  that  a student  will 
open  fire  in  class.  No  violence  is  reported, 
and  a student  is  suspended  for  starting  the 
rumor. 

25:  Cleveland  - Three  high  school  students  are 
convicted  of  plotting  a Columbine-style  at- 
tack at  their  school.  Police  confiscate  maps 
of  the  school,  a note  planning  a mass  suicide 
after  the  assault  and  weapons  from  the  boys' 
homes. 

26:  Merced,  CA  - A boy,  13,  fires  twice  with  a 
revolver  at  another  student  passing  in  a car 
in  front  of  his  school.  No  one  is  injured. 


26:  Omaha  - Two  high  school  sophomore  girls 
are  grazed  by  gunfire  as  they  wait  for  a bus 
in  front  of  their  school. 

27:  Battle  Ground,  Washington  - Security  is  tight- 
ened at  a high  school  after  three  days  of  graf- 
fiti threatening  to  kill  eight  black  students  at 
the  predominantly  white  school. 

February 

8:  Franklin,  Tennessee  - A middle  school  girl, 
12,  is  arrested  after  police  find  a pistol  and 
bullets  in  her  locker. 

10:  Yeadon,  PA  - A junior  high  student  is  accused 
of  trying  to  shoot  his  principal  and  a teacher 
after  a fight  with  another  student.  He  alleg- 
edly points  a gun  at  the  educators  and  pulls 
the  trigger  three  times.  The  gun  fails  to  dis- 
charge. 

14:  Chicago  - A student,  11,  suffers  a minor  gun- 
shot wound  when  a bullet  passes  through  a 
wall  of  his  elementary  classroom.  Police  say 
another  student,  also  11,  was  playing  with  a 
gun  in  a nearby  restroom. 

17:  Lebanon,  Ohio  - A high  school  senior  is  ar- 
rested and  suspended  after  police  find  a 
loaded  rifle  in  his  car  on  school  grounds. 

22:  Atlanta  - A girl,  12,  pulls  out  a loaded  hand- 
gun in  her  middle  school  cafeteria.  She  sur- 
renders the  gun  without  firing  and  is  ar- 
rested. 

24:  Tecumseh,  Oklahoma  - Shots  are  fired  in  a 
high  school  parking  lot  after  a fight  between 
students  over  a girlfriend. 

25:  Fairmont,  W.  VA  - Two  elementary  school 
boys,  ages  11  and  12,  are  caught  bringing 
homemade  bombs  to  school. 

28:  Memphis  - Two  seventh-graders  are  arrested 
after  a teacher  discovers  a gun  in  a classroom. 

28:  Austin,  Indiana  - A man  shoots  his  estranged 
wife  with  a shotgun  outside  their  child's  el- 
ementary school  as  the  woman  drops  her 
daughter  off.  The  man  later  takes  a hostage, 
and  the  two  are  found  dead  after  a police 
standoff  at  a nearby  liquor  store. 

29:  Mount  Morris  Township,  Michigan  - a girl, 
6,  is  shot  in  the  head  and  killed  in  class.  Po- 
lice arrest  a boy,  6,  a first-grade  classmate  of 
the  victim. 


J La  State  Med  Soc  VOL  152  October  2000  513 


Adolescent  Violence 


29:  Fort  Worth  - A student,  9,  is  suspended  for 
bringing  a hunting  knife  to  school. 

March 

1 : Palmetto,  Florida  - A high  school  sophomore 
is  stabbed  in  the  back  on  a school  bus  by  a 
girl  who  police  say  had  been  quarreling  with 
the  victim's  sister. 

1:  Socorro,  New  Mexico  - A homemade  bomb 
detonates  in  a locker  at  a high  school.  No  one 
is  injured;  five  students  are  arrested. 

7 : Tacoma,  Washington  - Three  high  school  stu- 
dents are  arrested  after  administrators  find 
a live  grenade  in  a locker. 

9:  New  York  - Two  students  are  stabbed  at  their 
high  school  by  a man  who  walked  onto  the 
campus  and  began  arguing  with  the  boys. 

9:  Woodbridge,  VA  - An  art  teacher  is  accused 
of  bringing  a gun,  stashed  in  her  backpack, 
into  school. 

10:  Chapel  Hill,  N.C.  - A student,  14,  is  grabbed 
by  the  throat  and  attacked.  A cafeteria  worker 
is  arrested. 

10:  Savannah,  GA  - A student,  16,  and  another 
person  are  shot  and  killed  as  they  leave  a 
high  school  dance  with  hundreds  of  other 
students.  A man,  19,  is  arrested. 

13:  West  Carrollton,  Ohio  - A middle  school  boy, 
13,  is  accused  of  spraying  his  teacher  in  the 
face  with  a fire  extinguisher. 

16:  Des  Moines  - Two  high  school  boys  are  sus- 
pended for  writing  a "hit  list"  of  16  class- 
mates to  be  killed. 

21:  Naples,  Idaho  - A sixth-grade  girl  is  sus- 
pended for  bringing  a handgun  to  class. 

23:  Joshua,  Texas  - A high  school  girl,  17,  suffers 
a broken  nose  and  two  black  eyes  in  an  at- 
tack by  a classmate,  who  strikes  her  repeat- 
edly with  a broken  bottle. 

23:  Lisbon,  Ohio  - A boy,  12,  walks  into  his  el- 
ementary school  with  a loaded  handgun  and 
orders  a dozen  social  studies  classmates  to 
the  floor.  He  later  surrenders  the  gun  to  a 
teacher. 

23:  Renton,  Washington  - A gym  teacher  and  a 
freshman  girl  are  assaulted  by  a student,  15, 
and  a man  during  a gym  class. 


24:  Delray  Beach,  Florida  - Acting  on  a tip,  school 
police  search  a high  school  student  and  find 
a gun,  five  knives,  two  sharpened  awls  and 
a bottle  of  liquor. 

24:  West  Grove,  PA  - A girl,  12,  is  caught  bring- 
ing a steak  knife  to  school.  Police  say  she  in- 
tended to  use  it  on  another  student. 

April 

4:  Rock  Island,  Illinois  - Thirty-one  high  school 
students  and  teachers  are  told  that  they  were 
named  in  a "death  list"  compiled  by  a stu- 
dent. The  student  is  suspended. 

6:  Dallas  - Three  boys  - two  9-year-olds  and  a 
14-year-old  - are  suspended  after  sneaking 
handguns  into  their  schools.  One  gun  was 
loaded. 

10:  Martin,  Tennessee  - A boy,  15,  is  arrested  af- 
ter police  discover  a loaded  handgun  in  his 
middle  school  gym  locker.  He  says  he  bought 
the  weapon  for  protection. 

10:  Fresno,  CA  - A high  school  sophomore  is  ar- 
rested after  carrying  a loaded  handgun  to 
school  and  threatening  to  kill  a vice-princi- 
pal. 

10:  New  York  - A girl,  9,  is  raped  in  a school  stair- 
well. Two  classmates,  both  12,  are  charged. 

In  light  of  these  facts,  it  is  amazing  to  realize, 
that  school  violence  is  estimated  to  be  under  re- 
ported by  as  much  as  fifty  percent.  Such  statis- 
tics bring  fear  into  our  youth  and  indicate  that 
going  to  school  is  one  of  the  hardest  challenges 
that  the  American  children  must  face; 

However,  in  spite  of  these  startling  statistics, 
school  is  one  of  the  safest  places  a child  can  be. 

WARNING  SIGNS 

Why  didn't  we  see  it  coming?  Usually  after  a 
violent  incident  has  occurred,  we  ask  this  ques- 
tion in  order  to  attempt  to  understand  what  we 
can  do  to  prevent  such  an  incident  from  reoc- 
curring. We  begin  to  rethink  the  happenings  in 
the  days  leading  up  to  the  incident — did  the 
youth  do  or  say  anything  that  should  have 
warned  us  as  to  what  was  going  to  happen? 


514  J La  State  Med  Soc  VOL  152  October  2000 


Adolescent  Violence 


There  are  early  warning  signs  (certain  behav- 
ioral and  emotional  signs)  in  most  cases  of  vio- 
lence to  self  or  others  that,  when  viewed  in  con- 
text, can  signal  a troubled  child.  However,  early 
warning  signs  are  only  indicators  that  a student 
may  need  help.  These  signs  may  or  may  not  in- 
dicate a serious  problem  but  rather,  they  pro- 
vide us  with  the  opportunity  to  address  concerns 
and  the  child's  needs.  Early  warning  signs  en- 
able others  to  act  responsibly  by  getting  help  for 
the  child  before  problems  escalate.  These  early 
warning  signs  can  help  frame  concern  for  a child 
but  should  not  result  in  inappropriately  label- 
ing or  stigmatizing  individual  students  because 
they  appear  to  fit  a certain  profile  of  early  warn- 
ing signs.  It  is  appropriate  to  be  concerned  or 
worried  for  the  child  but  not  appropriate  to  over- 
react and  jump  to  conclusions.  The  warning 
signs  are  intended  to  aid  others  in  identifying 
and  referring  children  who  may  need  help.  In 
order  to  avoid  misinterpreting  early  warning 
signs,  one  should  utilize  the  following  prin- 
ciples:1 2 3 4 5 

1.  Do  no  harm — first  and  foremost  the  intent 
should  be  to  get  help  for  a troubled  child  early 
and  not  use  the  warning  signs  as  a checklist 
for  formally  identifying,  mislabeling,  or  stereo- 
typing children. 

2.  Understand  violence  and  aggression  within  a 
context — recognize  that  violent  and  aggressive 
behaviors  may  have  many  antecedent  factors 
that  exist  within  the  school,  the  home,  and  the 
larger  social  environment.  Some  children  may 
act  out  if  stress  becomes  too  great,  if  they  lack 
positive  coping  skills;  and  if  they  have  learned 
to  react  to  stress  with  aggression. 

3.  Avoid  stereotypes 

4.  View  warning  signs  within  a developmental 
context — know  the  stages  of  development  and 
what  is  developmentally  typical  behavior  in 
order  to  avoid  misinterpreting  behaviors. 

5.  Realize  and  understand  that  youth  typically 
exhibit  multiple  warning  signs — do  not  over- 
act to  single  signs,  words,  or  actions,  as  most 
children  who  are  at  risk  for  aggression  exhibit 
more  than  one  warning  sign,  repeatedly,  and 

with  increasing  intensity  over  time. 


For  the  toddler  and  preschool  child,  some  of  the 
warning  signs  are:  has  many  temper  tantrums 
in  a single  day  or  several  lasting  more  than  15 
minutes,  and  cannot  be  calmed  by  parents,  fam- 
ily members,  or  other  care  givers;  is  extremely 
active,  impulsive,  and  fearless;  consistently  re- 
fuses to  follow  directions  and  listen  to  adults; 
doesn't  seem  attached  to  parents;  and  frequently 
watches  violence  on  television,  engages  in  play 
that  has  violent  themes,  or  is  cruel  to  other  chil- 
dren.6 

For  the  school-aged  child,  warning  signs  are: 
has  trouble  paying  attention  and  concentrating; 
often  disrupts  classroom  activities;  does  poorly 
in  school;  frequently  gets  into  fights;  is  easily 
frustrated;  reacts  to  disappointments,  criticism, 
or  teasing  with  intense  anger,  blame,  or  revenge; 
watches  many  violent  television  shows  and 
movies  or  plays  a lot  of  violent  video  games;  has 
few  friends,  and  is  often  rejected  by  other  chil- 
dren because  of  his  or  her  behavior;  makes 
friends  with  other  children  known  to  be  unruly 
or  aggressive;  history  of  discipline  problems; 
expression  of  violence  in  writings  and  drawings; 
patterns  of  impulsive  and  chronic  hitting,  intimi- 
dating and  bullying  behaviors;  a victim  of  vio- 
lence; consistently  does  not  listen  to  adults;  is 
not  sensitive  to  the  feelings  of  others;  serious 
threats  of  violence;  and  is  cruel  or  violent  toward 
pets  or  other  animals.6 

For  the  pre-teen  or  teenager,  the  warning 
signs  are:  consistently  doesn't  listen  to  author- 
ity figures;  disregards  the  feelings  or  rights  of 
others;  mistreats  others  and  seems  to  rely  on 
physical  violence  or  threats  of  violence  to  solve 
problems;  often  expresses  that  he  or  she  feels  that 
life  has  been  unfair;  does  poorly  in  school  and 
often  skips  class;  misses  school  frequently  for 
no  known  reason;  gets  suspended  or  drops  out 
of  school;  uncontrolled  anger;  joins  a gang,  gets 
involved  in  fighting,  stealing,  or  destroying 
property;  uses  alcohol  or  drugs;  lack  of  interest 
in  school;  history  of  discipline  problems;  absence 
of  age-appropriate  anger  control  skills;  feelings 
of  being  picked  on  and  persecuted;  victim  of 
violence;  persistent  disregard  for  or  refusal  to 
follow  rules;  cruelty  to  pets  or  other  animals;  any 


J La  State  Med  Soc  VOL  152  October  2000  515 


Adolescent  Violence 


artwork  or  writing  that  is  bleak,  violent,  or  de- 
picts isolation  or  anger;  constantly  talks  about 
weapons  or  violence;  seems  to  be  obsessed  with 
violent  games  and  TV  shows;  depression  or 
mood  swings;  brings  a weapon  to  school;  pat- 
terns of  impulsive  and  chronic  hitting,  intimi- 
dating, and  bullying  behaviors;  unwarranted 
jealousy;  involvement  with  or  interest  in  gangs; 
social  withdrawal;  serious  threats  of  violence; 
and  talking  about  bringing  weapons  to  school.6 

One  must  remember  that  the  presence  of  a 
single  symptom  does  not  necessarily  indicate  a 
call  for  remediation;  however,  the  more  of  these 
signs  that  are  noticed,  the  greater  the  chance  that 
the  young  person  needs  help.  Recognizing  these 
signs  in  any  child  should  be  a cause  for  alarm 
for  any  professional,  parent,  or  community 
member. 

Imminent  warning  signs  are  different  from 
early  warning  signs  in  that  they  indicate  that  a 
student  is  very  close  to  behaving  in  a way  that 
is  potentially  dangerous  to  self  or  to  others. 
These  situations  require  an  immediate  response. 
Imminent  warning  signs  usually  occur  as  a se- 
quence of  overt,  serious,  hostile  behaviors  or 
threats  that  are  directed  toward  others.  Immi- 
nent warning  signs  are  usually  evident  to  more 
than  one  person.  Imminent  warning  signs  may 
include  the  following:5 

1.  Serious  physical  fighting  with  peers  or  fam- 
ily members. 

2.  Severe  destruction  of  property. 

3 . Out-of-control  rage  for  seemingly  minor  rea- 
sons. 

4.  Very  detailed  threats  of  lethal  violence 

5.  Possession  and/or  use  of  weapons,  includ- 
ing firearms. 

6.  Other  behaviors  that  are  self-injurious  or  in- 
volve threats  of  suicide. 

If  warning  signs  indicate  that  a dangerous  situ- 
ation is  imminent,  the  first  and  foremost  con- 
sideration must  always  be  the  safety  of  all  con- 
cerned. 

What  happens  when  early  and  imminent 
signs  are  recognized  in  a child?  It  is  certainly 


appropriate  for  others  to  be  concerned  when 
these  signs  are  noted  and  even  more  appropri- 
ate to  do  something  about  those  concerns.  In  fact, 
for  communities,  schools,  and  parents,  under- 
standing and  recognizing  early  and  imminent 
warning  signs  is  an  essential  and  crucial  step  in 
ensuring  a safe  environment  for  our  youth  and 
for  developing  prevention  approaches  to  youth 
violence. 

CHARACTERISTICS  OF 
A SAFE  SCHOOL  ENVIRONMENT 

The  problem  of  school  violence  is  felt  on  many 
levels  in  the  school  setting.  The  threat  of  such 
violence  can  close  children's  minds  to  learning 
and  prevent  teachers  from  teaching  effectively. 
Teachers  tend  to  find  themselves  spending  in- 
creasing amounts  of  time  dealing  with  students' 
disruptive  and  inappropriate  behavior  in  the 
classroom,  interpersonal  conflicts  in  and  outside 
of  the  classroom,  and  off-task  behavior  on  as- 
signments. Unfortunately,  many  of  these  chil- 
dren have  not  learned  appropriate  and  effective 
ways  to  deal  with  their  feelings  and  conflicts.  It 
is  important  to  note  that  although  schools  are 
clearly  not  the  cause  of  youth  violence,  they  can 
provide  the  students  with  options  to  violent  be- 
havior and  give  the  students  a model  for  appro- 
priate social  behavior.  If  schools  and  society  are 
informed,  they  will  be  in  a better  position  to  for- 
mulate a plan  of  action  that  will  foster  learning, 
safety,  and  socially  appropriate  behaviors  and 
reduce  the  possibility  of  violence  occurring  in 
schools  and  in  the  broader  community.  Well- 
functioning schools  have  formulated  a plan  that 
fosters  learning,  safety,  and  socially  appropri- 
ate behaviors.  Safe  schools  that  have  effective 
prevention,  intervention,  and  crisis  response 
strategies  are  characterized  by  the  following:5 

1.  Focuses  on  academic  achievement — They 
believe  and  convey  the  belief  that  all  chil- 
dren can  academically  achieve  and  can  be- 
have appropriately.  This  is  done  in  such  a 
way  that  allows  for  and  appreciates  indi- 
vidual differences.  Expectations  are  clearly 


516  J La  State  Med  Soc  VOL  152  October  2000 


Adolescent  Violence 


communicated  while  emphasizing  the  re- 
sponsibility of  the  students,  parents,  and  the 
school  in  meeting  these  expectations. 

2.  Involves  families  in  meaningful  ways — 
Schools  recognize  the  importance  of  family 
support  and  make  every  attempt  to  posi- 
tively engage  families  in  the  child's  educa- 
tion. 

3.  Develops  links  to  the  community — Schools 
realize  that  very  strong  close  ties  to  the  com- 
munity improve  the  opportunity  to  reduce 
school  violence  and  to  better  serve  those  chil- 
dren who  are  at  risk  for  violence. 

4.  Emphasizes  positive  relationships  among 
students  and  staff — Research  has  proven  that 
a strong  positive  relationship  with  a support- 
ing adult  when  most  needed  is  one  of  the 
most  crucial  factors  in  preventing  student 
violence.  Effective  schools  make  sure  that  op- 
portunities are  available  whereby  adults 
spend  quality,  personal  time  with  students 
and  they  encourage  positive  student  inter- 
personal relations. 

5.  Openly  discuss  safety  issues — Schools  teach 
children  the  dangers  of  firearms,  how  to  ap- 
propriately deal  with  feelings,  express  anger 
and  handle  conflicts,  how  to  make  choices, 
and  to  accept  responsibility  for  their  choices 
and  actions. 

6.  Treats  students  with  equal  respect — Schools 
must  communicate  to  students  as  well  as  the 
community  that  all  children  are  valued,  re- 
spected, and  treated  equally. 

7.  Creates  ways  for  students  to  share  their  con- 
cerns— It  has  been  established  that  peers  are 
often  most  likely  to  know  in  advance  of  the 
possibility  of  school  violence.  Therefore  it  is 
imperative  that  schools  establish  ways  for 
students  to  safely  report  troubling  behaviors. 

8.  Helps  children  feel  safe  in  expressing  their 
feelings — Schools  must  make  sure  that  not 
only  do  students  have  access  to  a caring  sup- 
portive adult  but  also  feel  safe  when  express- 
ing their  needs,  fears,  and  anxieties. 

9.  Has  a system  in  place  for  referral  of  children 
who  may  be  victims  of  abuse  or  neglect. 

10.  Offers  extended  day  programs  for  stu- 


dents— School-based  before  and  after  school 
programs  can  be  very  effective  in  reducing 
violence. 

11.  Promotes  good  citizenship  and  character — 
Schools  place  emphasis  on  students  becom- 
ing responsible  citizens  as  well  as  achieving 
academically. 

12.  Identifies  problems  and  assesses  progress  to- 
ward solutions — Schools  must  continually 
and  objectively  assess  areas  of  concern  in- 
cluding potentially  dangerous  situations  and 
strive  to  resolve  these  issues. 

13.  Supports  students  in  the  transition  to  adult 
life  and  the  workplace — Youth  need  assis- 
tance in  planning  for  their  future  and  in  de- 
veloping those  skills  that  will  enhance  their 
ability  in  becoming  a productive  member  of 
society. 

Schools  can  clearly  provide  the  arena  for  stu- 
dents to  develop  skills  in  preventing  violence. 
They  are  a crucial  link  in  providing  a safe  and 
responsive  foundation  that  helps  all  children  and 
ultimately  impacts  society. 

PREVENTION 

Youth  violence,  especially  school  violence,  re- 
flects a much  broader  problem,  one  that  can  be 
addressed  only  when  everyone — at  school,  at 
home,  and  in  the  community — works  together. 
What  can  be  done?  Prevention  is  the  key.  All 
forms  of  violence  have  one  thing  in  common — 
violence  is  learned  behavior.  Therefore,  if  it  is 
learned  behavior,  it  can  be  changed.  Why  do  our 
nation's  youth  fail  to  display  appropriate  behav- 
ior? These  youth  fail  to  act  in  a socially  accept- 
able manner  because  of  the  following:5 

1.  They  don't  know  what  appropriate  behav- 
ior is  due  to  a lack  of  modeling  of  alterna- 
tive ways  of  resolving  conflict. 

2.  They  have  the  knowledge  but  lack  the  prac- 
tice due  to  inadequate  reinforcement. 

3.  They  have  emotional  responses,  such  as  an- 
ger, fear,  or  anxiety  which  inhibit  the  perfor- 
mance of  desirable  behavior. 


J La  State  Med  Soc  VOL  152  October  2000  517 


Adolescent  Violence 


4.  They  have  inappropriate  beliefs  and  attribu- 
tions regarding  aggression. 

5.  Or,  they  have  developmental  delays  due  to 
physiological  problems,  sometimes  caused 
by  the  mother's  substance  abuse  during 
pregnancy. 

Children  from  dysfunctional  homes,  as  well  as 
homes  which  lack  adult  supervision,  often  fail 
to  learn  problem-solving  skills  which  would 
help  them  achieve  more  socially  acceptable  so- 
lutions to  everyday  problems.  High-risk  children 
are  frequently  victims  of  violence  themselves. 
Violence  tends  to  be  an  intergenerational  prob- 
lem, with  children  imitating  the  deficient  social 
skills  of  their  own  parents.  Recent  studies  have 
revealed  peer  group  pressure  to  be  the  fastest 
growing  and  most  disturbing  cause  of  violence 
among  today's  youth,  whether  in  school  or  out. 
Youth  involvement  with  drugs  and  alcohol  has 
also  been  cited  as  a major  factor  contributing  to 
school  violence.  Research  also  indicates  that  the 
media  has  an  influence  on  youth  violence  as  vio- 
lent programs  reinforce  the  message  that  vio- 
lence is  acceptable  and  that  it  is  okay  to  domi- 
nate others.  In  fact,  research  shows  that  children 
who  view  these  programs  act  more  aggressively 
with  their  peers  than  children  who  do  not.  It  is 
evident  in  looking  at  contributing  factors  of 
youth  violence,  that  there  are  many  contribut- 
ing factors  to  this  problem.  With  this  in  mind, 
the  major  challenge  for  society  then  becomes 
how  do  we  reduce  violence  among  our  youth 
(both  as  victims  and  victimizers)  and  provide 
them  with  the  skills  designed  to  reduce  impul- 
sive and  aggressive  behavior  and  increase  their 
level  of  social  competence?  What  is  the  best 
method  of  prevention?  One  belief  is  that  the  best 
way  to  address  the  issue  of  violence  in  schools 
is  to  simply  get  tougher  with  the  perpetrators. 
Yet,  others  feel  that  the  solution  to  violence 
would  be  better  met  by  instilling  moral  values 
for  children  who  are  confused  as  a result  of  me- 
dia pollution.  Others  feel  that  the  solution  to  the 
problem  is  to  attack  violence  at  its  roots  through 
a number  of  different  measures,  such  as  provid- 
ing training  in  parenting  skills,  providing  the 


entire  family  with  social  and  economic  supports 
and  training  in  nonviolent  conflict  resolution, 
and  providing  youth  with  a strong  sense  of  right 
and  wrong  and  a safe  community  in  which  to 
develop  and  grow.  Each  solution  used  by  itself 
is  too  simplistic  and  not  effective;  however,  these 
three  options  used  together  make  a strong  pro- 
gram for  reducing  or  stemming  youth  violence 
in  schools  and  in  communities. 

Of  the  three  types  of  prevention — primary, 
secondary,  tertiary — which  would  be  most  ef- 
fective and  have  the  greatest  impact  for  youth, 
schools,  communities,  and  society  in  general?  Is 
it  more  beneficial  to  offer  solutions  to  youth  vio- 
lence after  a violent  incident  occurs,  such  as  the 
shootings  at  Columbine,  or  to  reach  children 
before  problems  and  high-risk  behaviors  that 
lead  to  violence  start?  Cowen  says,  "It  may  be 
easier  to  lay  foundations  of  wellness  from  the 
start  than  to  promote  wellness  in  the  absence  of 
such  foundations."7  Perhaps  the  old  adage  "An 
ounce  of  prevention  is  the  best  medicine"  is  the 
approach  that  society  must  use  in  hopes  of  re- 
ducing this  devastating  and  debilitating  prob- 
lem. The  key  features  of  primary  prevention  ef- 
forts are  that  it  is  offered  to  all  members  of  a 
population  who  may  or  may  not  be  considered 
to  be  "at  risk",  is  voluntary,  attempts  to  influ- 
ence societal  forces  which  impact  parents  and 
children,  and  seeks  to  promote  positive  function- 
ing rather  than  just  to  prevent  problems.  Accord- 
ing to  the  US  Department  of  Justice,  when  there 
is  an  increase  in  the  capacity  of  students  to  use 
moral  reasoning  and  empathy  to  make  decisions, 
there  is  a reduction  in  juvenile  delinquency.  The 
article  "Peer  Mediation  in  the  Schools:  Teaching 
Conflict  Resolution  Techniques  to  Students" 
states  that  "the  presentation  of  conflict  resolution 
skills  can  be  an  effective  alternative  to  the  only 
two  choices  many  students  face  today — fight  or 
flee."8 

The  US  Department  of  Education,  Health 
and  Human  Services  and  the  Department  of  Jus- 
tice, are  emphasizing  a comprehensive,  inte- 
grated community-wide  approach.  This  ap- 
proach provides  services  and  activities  that  tar- 
get the  youths'  development  of  the  social  skills 


518  J La  State  Med  Soc  VOL  152  October  2000 


Adolescent  Violence 


and  the  emotional  resilience  needed  in  order  to 
reduce  and/or  prevent  drug  use  and  violent 
behavior  and  to  establish  a safe  and  disciplined 
school  environment.1 2 3 4 5 6 7 8 9  In  1998,  Janet  Reno,  At- 
torney General,  US  Department  of  Justice,  stated 
"an  effective  and  safe  school  is  the  vital  center 
of  every  community  whether  it  is  in  a large  ur- 
ban area  or  a small  rural  community.  There 
should  be  an  overall  effort  to  make  sure  that 
every  school  in  this  nation  has  a comprehensive 
violence  prevention  plan  in  place."  There  is 
ample  documentation  that  prevention  and  early 
intervention  efforts  can  reduce  violence  and 
other  troubling  behaviors  in  schools.  In  1998,  the 
National  Education  Goal  was  that  by  the  year 
2000  "all  schools  in  America  will  be  free  of  drugs 
and  violence  and  offer  a disciplined  environ- 
ment that  is  conducive  to  learning."9  Obviously 
this  goal  has  not  been  met  which  indicates  that 
we  continue  to  face  the  challenge  of  youth  vio- 
lence in  our  schools,  communities,  and  society. 

There  are  no  easy  or  "quick-fix-it"  remedies 
to  the  problem  of  youth  violence.  Careful  plan- 
ning and  thought  must  go  into  deciding  how 
best  to  meet  this  challenge.  Therefore,  in  con- 
sidering what  can  be  done  to  reduce  or  elimi- 
nate youth  violence  in  our  society,  it  is  impor- 
tant to  look  at  what  programs  offer  and  to  de- 
termine if  we  are  focusing  on  short-term  ben- 
efits or  long-term  benefits.  Violence  prevention- 
only  programs  utilize  one  or  more  of  the  follow- 
ing plans:10 

1.  Eliminates  weapons 

2.  Suppresses  violent  behavior 

3.  Trains  faculty  and  staff  to  intervene 

4.  Targets  students  who  commit  the  most  vio- 
lent acts 

5.  Teaches  selected  students  how  to  manage 
anger 

6 . Encourages  students  to  abstain  from  violence 

7.  Creates  a district  task  force  to  identify  causes 
of  violence 

8.  Adopts  a threat-management  policy 

9.  Provides  debriefing  sessions  for  students 
traumatized  by  violent  incidents 

10.  Initiates  a weapons  hotline 


Comprehensive  violence  prevention  programs 
use  all  of  the  following  components:10 

1.  Meets  nurturing  needs 

2.  Creates  a cooperative  environment 

3.  Encourages  positive  and  lasting  relation- 
ships 

4.  Timits  out-of-school  time 

5.  Forms  partnerships  with  parents  and  com- 
munities 

6.  Provides  long-term  conflict  resolution /peer 
mediation  training  to  all  students 

7.  Includes  components  from  violence  preven- 
tion only  programs 

Most  effective  violence  prevention  programs  do 
the  following:  make  an  accurate  assessment  of 
violence;  use  all  the  resources  in  the  community; 
incorporate  family  services  into  both  commu- 
nity and  school  programs;  intervene  early  in  a 
child's  life;  include  not  only  anti- violence  strat- 
egies but  also  positive  experiences;  create  and 
communicate  clearly  defined  behavior  codes 
and  enforce  them  strictly  and  uniformly;  and 
prepare  to  engage  in  a long-term  effort.2 

Prevention  efforts  have  been  successful  in 
four  areas:  in  schools,  with  families,  with  pro- 
fessionals, and  with  the  community.  Schools  are 
becoming  more  and  more  aware  of  the  need  to 
integrate  prevention  materials  into  the  curricu- 
lum. Schools  are  clearly  not  the  cause  of  youth 
violence,  but  they  can  provide  the  students  with 
options  to  violent  behavior  and  give  the  students 
a model  for  appropriate  social  behavior.  Schools 
clearly  can  provide  the  arena  for  students  to 
develop  skills  in  preventing  violence.  By  incor- 
porating a violence  prevention  curriculum  into 
the  classroom,  educators  will  provide  children 
with  the  opportunity  to  learn  how  to  deal  with 
anger  constructively,  how  to  communicate  feel- 
ings and  concerns  without  using  violence  and 
abusive  language,  how  to  think  critically  about 
alternative  solutions,  and  how  to  become  healthy 
and  independent  problem  solvers.  It  is  impera- 
tive that  children  be  empowered  with  knowl- 
edge of  and  skills  in  the  following  areas:  prob- 
lem solving,  anger  management,  conflict  reso- 


J La  State  Med  Soc  VOL  152  October  2000  519 


Adolescent  Violence 


lution,  empathy,  self  esteem,  power  of  choices, 
social  skills,  impulse  control,  refusal  skills  which 
help  youth  resist  using  substances  and  engag- 
ing in  harmful  activities  and  relationships,  per- 
sonal safety,  how-to-get  along,  diversity,  medi- 
tation, and  the  effects  of  alcohol  or  drug  use.  Our 
youth  must  be  taught  that  actions  and  choices 
have  consequences  and  that  they  must  accept 
responsibility  for  their  personal  behavior  and 
actions.  They  must  learn  that  they  are  person- 
ally accountable  for  what  they  do  in  school  and 
in  the  community.  It  must  also  be  recognized  that 
youth  can  play  a major  part  in  reducing  violence 
and  creating  safe  environments.  The  following 
are  ways  that  youth  can  reduce  violence:5 

1.  Settle  arguments  with  words  rather  than 
fighting  or  using  weapons.  Don't  gather 
around  when  others  are  arguing  or  fighting 
as  a group  makes  a good  target  for  violence. 

2.  Learn  safe  routes  for  walking  in  the  neigh- 
borhood as  well  as  knowing  safe  places  to 
seek  help. 

3.  Report  any  crimes  or  suspicious  actions. 

4.  If  home  alone,  don't  open  the  door  to  strang- 
ers or  to  anyone  you  don't  trust. 

5.  Never  go  anywhere  with  anyone  you  don't 
know  and  trust. 

6.  If  someone  tries  to  abuse  you,  say  no,  get 
away,  and  tell  a trusted  adult.  Always  trust 
your  feelings. 

7.  Don't  use  alcohol  or  other  drugs  and  avoid 
places  and  people  who  are  associated  with 
drugs  and  alcohol. 

8.  Choose  friends  who  are  also  against  violence 
and  drugs  and  stay  away  from  known 
trouble  spots. 

9.  Get  involved  in  your  school  to  make  it  a safer 
and  better  place — poster  contests  against  vio- 
lence; anti-drug  rallies;  random  acts  of  kind- 
ness week;  mediation  training;  etc. 

10.  Be  a good  role  model  by  setting  a good  ex- 
ample and  helping  younger  children  learn 
how  to  avoid  being  crime  victims  or  victim- 
izes. 

11 . Volunteer  to  be  a mentor  for  younger  students. 

12.  Participate  in  violence  prevention  programs 


such  as  peer  mediation  and  conflict  resolu- 
tion and  use  those  newly  learned  skills  in  the 
home,  neighborhood,  school,  and  commu- 
nity. 

13.  Listen  to  friends  and  encourage  them  to  seek 
help  if  needed  or  seek  help  for  them. 

14.  Develop  or  participate  in  activities  that  pro- 
mote diversity,  understanding  of  differences 
and  respect  for  the  rights  of  everyone. 

15.  Refrain  from  bullying,  teasing,  and  intimi- 
dating peers. 

Students  have  a responsibility  to  be  involved  in 
solving  the  problem  of  youth  violence  and  rec- 
ognizing what  they  can  do  to  help  create  safe 
schools  and  impact  society. 

PILOT  PROGRAM 

The  University  of  Louisiana  at  Monroe  Social 
Work  Program  through  a grant  funded  by  the 
Louisiana  Children's  Trust  Fund  has  been  pro- 
viding violence  prevention  and  life-skills  train- 
ing to  elementary  and  secondary  students  in 
Ouachita  Parish  and  surrounding  parishes.  This 
program  was  taught  to  all  students  rather  than 
targeting  a select  few.  This  approach  allowed  the 
program  to  reach  the  maximum  number  of  fu- 
ture adults.  This  program  incorporated  training 
in  stress  management,  conflict  resolution,  sub- 
stance abuse,  gender  relationships,  self  esteem, 
problem  solving,  anger  management,  empathy, 
choices,  social  skills,  impulse  control,  refusal 
skills  to  drugs,  personal  safety,  how-to-get-along, 
diversity,  and  mediation.  Attempts  to  measure 
the  effectiveness  of  the  material  taught  in  the 
school  setting  ranged  from  observation  of  the 
children  by  the  teachers  and  social  work  interns 
to  a questionnaire  completed  by  the  teachers. 
Observation  of  the  behaviors  of  the  children  in 
the  classroom,  in  the  cafeteria,  and  on  the  play- 
ground indicated  an  improvement  in  the 
student's  behavior.  Prior  to  exposure  to  the  cur- 
riculum, students  tended  to  be  more  aggressive 
toward  others,  to  tease  others,  and  to  engage  in 
fights.  However,  after  participating  in  the  pre- 
vention and  life-skills  training  program,  these 


520  J La  State  Med  Soc  VOL  152  October  2000 


Adolescent  Violence 


same  students  were  observed  to  be  getting  along 
much  better  with  their  peers  and  to  exhibit  a 
decrease  in  aggressive  behaviors.  The  question- 
naire survey  revealed  a significant  improvement 
in  the  social  skills  used  by  students.  The  num- 
ber of  students  referred  for  disciplinary  mea- 
sures has  significantly  decreased  since  involve- 
ment in  the  program.  Each  year  that  the  results 
of  the  program  have  been  measured,  significant 
increases  in  the  students'  behaviors  in  the  fol- 
lowing areas  have  been  noted:  50%  increase  in 
ability  to  use  empathy  skills;  50%  increase  in 
ability  to  use  problem-solving  techniques;  67% 
increase  in  ability  to  use  anger  management 
skills;  and  67%  increase  in  their  self  esteem.  As 
a result  of  this  program,  students  are  better  pre- 
pared to  cope  with  peer  pressure,  frustrations, 
conflict,  and  societal  expectations.  There  has 
been  a decline  in  negative  confrontations,  ag- 
gressive behavior,  and  violence  in  the  schools. 
As  this  program  continues  to  reach  the  youth  of 
today,  efforts  to  assess  its  effectiveness  will  con- 
tinue. The  benefits  of  this  training  extend  beyond 
schools  as  it  prepares  students  to  manage  future 
conflicts  constructively  in  career,  family,  com- 
munity, national,  and  international  settings.  The 
data  compiled  thus  far  clearly  indicate  the  need 
for  additional  programs  similar  in  design  and 
implementation. 

Never  before  has  the  need  for  violence  pre- 
vention skills  in  the  classroom  been  so  great. 
School-based  violence  prevention  programs  are 
designed  to  expose  children  to  positive  ways  of 
dealing  with  their  feelings  and  resolving  con- 
flicts. Such  programs  show  students  how  to  rec- 
ognize a potentially  violent  situation,  determine 
the  best  response,  and  stay  in  control.  Compre- 
hensive public  school  violence  prevention  edu- 
cation programs,  beginning  in  preschool  years 
and  available  to  all  families,  offer  great  promise 
to  our  youth  to  learn  to  manage  conflicts  con- 
structively and  to  gain  better  control  over  their 
own  lives.  In  order  for  today's  children  to  be- 
come tomorrow's  healthy  adults,  they  must  be 
prepared  with  the  knowledge  and  ability  to  ap- 
ply generalized  skills  to  everyday  experiences. 
This  prevention  program  that  has  been  offered 


to  schools  in  northeast  Louisiana  holds  great 
promise  in  reducing  violence  in  all  its  forms  and 
in  enhancing  the  future  potential  of  our  youth. 

Although  this  program  has  proven  to  be  ef- 
fective, it  is  apparent  that  the  information  needs 
to  be  developed  gradually  and  continuously  at 
all  levels  with  increasing  complexity  and  sophis- 
tication so  that  students  can  improve  expertise. 
For  youth  to  become  competent  in  the  use  of 
these  skills,  they  need  years  of  continued  prac- 
tice. Children  are  our  future  and  as  such  we  need 
to  provide  them  with  the  skills  that  will  afford 
them  the  opportunity  to  become  productive 
members  of  society. 

CONCLUSIONS  AND  THE  FUTURE 

As  stated  earlier,  the  goal  is  for  all  schools  in 
America  to  be  free  of  drugs  and  violence  and 
the  unauthorized  presence  of  firearms  and  al- 
cohol, and  to  offer  a disciplined  environment 
that  is  conducive  to  learning.  However,  since  we 
are  well  into  the  year  2000  and  youth  violence 
in  schools  and  in  the  community  continues  to 
be  of  great  concern  to  the  American  public,  we 
obviously  have  not  reached  this  goal.  Does  this 
imply  that  our  prevention  efforts  have  been  un- 
successful and  that  we  have  failed?  Or  perhaps, 
it  would  be  more  accurate  to  state  that  we  have 
begun  to  recognize  that  ending  the  problem  of 
youth  violence  is  complex  and  must  involve 
everyone.  Perhaps  the  challenge  for  society  is 
recognizing  that  prevention  strategies  alone  are 
not  enough.  Around  the  country,  concern  about 
increasing  youth  violence  is  resulting  in  a vari- 
ety of  innovative  and  potentially  effective  pro- 
grams. How  can  we  determine  which  programs 
work  and  best  meet  the  particular  needs  of  our 
community?  The  most  effective  programs  are 
designed  to  reduce  youth  violence;  make  an  ac- 
curate assessment  of  the  existence  of  violence, 
and,  especially,  gang  activity;  use  all  the  re- 
sources in  the  community,  social  services,  law 
enforcement,  schools,  medical  profession,  com- 
munities, families;  incorporate  family  services 
into  both  community  and  school  programs;  in- 
tervene early  in  a child's  life;  include  positive 


J La  State  Med  Soc  VOL  152  October  2000  521 


Adolescent  Violence 


experiences  as  well  as  anti- violence  strategies; 
create  and  communicate  clearly  defined  behav- 
ior codes  and  strictly  and  uniformly  enforce  such 
codes;  replace  violent  behavior  with  nonviolent 
or  positive  behavior;  and  prepare  to  engage  in  a 
long-term  effort.  This  approach  involves  chang- 
ing attitudes,  values,  and  perspectives,  and  this 
change  does  not  occur  quickly  or  easily  We  did 
not  get  to  this  point  overnight  and  we  will  not 
resolve  the  problem  overnight.  In  fact,  if  we  con- 
sider the  fact  that  it  took  30  years  to  reduce  smok- 
ing in  the  United  States  and  15  years  to  reduce 
drunk  driving,  then  we  may  realize  that  reduc- 
ing youth  violence  may  take  even  longer.  With 
society's  "fast-food  approach"  to  solving  soci- 
etal ills,  perhaps  the  biggest  challenge  is  to  be 
willing  to  engage  in  long-term  efforts  to  solve 
the  problem  of  youth  violence.  Through  close 
collaboration  among  all  segments  of  society,  suc- 
cess is  possible.  Are  we  ready  for  the  challenge? 

REFERENCES 

1.  Schwartz  W.  An  overview  of  strategies  to  reduce 
school  violence.  Clearinghouse  on  Urban  Education 
Digest  115:  1996.  Available  at:  http:/  /ericweb. 
tc.columbia.edu  / digests  / digll5.html. 

2.  Kaufman  P,  Chen  X,  Choy  SP,  et  al.  Executive 
Summary ‘.Indicators  of  School  Crime  and  Safety.  Wash- 
ington, DC:  US  Department  of  Justice;  1998:1-8. 


3.  National  Crime  Prevention  Council.  Involving  Youth 
in  Violence  Prevention.  The  Eipman  Report.  Washing- 
ton, DC:  Bureau  of  Justice  Assistance;  1993:1-58. 

4.  Rosenstein  B,  Bowles  S,  Wasson  H.  Threat  of  vio- 
lence throughout  school  year.  USA  Today.  April  14, 
2000:13A. 

5.  Dwyer  K,  Osher  D,  Warger  C.  Early  Warning  Timely 
Response:  A Guide  to  Safe  Schools.  Washington,  DC: 
US  Department  of  Education;  1998:1-34. 

6.  American  Psychological  Association  and  American 
Academy  of  Pediatrics.  Potential  Warning  Signs  for 
Violence  in  Children.  Elkgrove  Village,  Illinois:  1997. 
Available  at:  http://www.uncg.edu/ericcass 
violence/  docs/ warning.html 

7.  Cowen  E.  In  Pursuit  of  Wellness.  Am  Psychol 
1991;46:404-408. 

8.  Morse  PS,  Andrea  R.  Peer  mediation  in  the  schools: 
teaching  conflict  resolution  to  students.  NAASP 
Bulletin  1994;78. 

9.  US  Department  of  Education.  Safe  Schools/Healthy 
Students  Initiative.  Washington,  DC:  US  Department 
of  Education;  1999:1-131. 

10.  Johnson  DW,  Johnson  RT.  Reducing  School  Violence  Through 
Conflict  Resolution.  Association  for  Supervision  and  Cur- 
riculum Development;1997.  Available  at:  http:/  / 
www.ascd.org  / books  / johnsonreducebook.html#chapl 


Ms  Melton  is  a licensed  clinical  social  worker 
and  is  Head  of  the  Social  Worker  Program  at  the 
University  of  Louisiana,  Monroe , Louisiana. 


522  J La  State  Med  Soc  VOL  152  October  2000 


Adolescent  Violence 


Children,  Adolescents,  and  Guns  in  Louisiana: 

A Thought  Experiment 

Holley  Galland,  MD 


More  children  and  youth  in  Louisiana  die  from  firearm  injuries  than  from  any  other  injury,  including 
motor  vehicle  accidents.  Many  survive  their  injuries  to  lead  lives  with  permanent  disabilities.  The  cost  to 
the  victims  and  to  society  as  a whole  is  enormous.  What  is  the  best  way  to  address  this  issue?  What  is  the 
physician’s  role,  both  as  an  individual  and  as  a member  of  a medical  organization?  This  paper  describes  a 
way  of  thinking  about  firearm  injury  prevention.  It  introduces  the  reader  to  the  Haddon  Matrix  and  the 
Intervention  Decision  Matrix.  It  then  reviews  six  options  and  offers  one  model,  motor  vehicle  injury  reduction, 
as  a way  to  consider  intervention  options. 


What  is  a thought  experiment?  It  is  a 
method  used  by  physicists  and  other 
scientists  to  think  through  the  pro- 
cess of  an  experiment  to  its  conclusion  without 
having  to  perform  the  experiment.  This  is  gen- 
erally done  when  theory  is  established  and  gen- 
erally accepted.  While  it  may  be  argued  that  very 
little  is  generally  accepted  in  firearm  issues,  I 
choose  this  approach  because  this  lack  of  con- 
sensus makes  deciding  upon  appropriate  action 
more  difficult  and  careful  planning  more  impor- 
tant. There  are  limited  resources  to  apply  to  any 
problem  in  health. 

What  is  the  problem?  For  the  purpose  of  this 


paper,  I will  define  the  problem  as  child  and  ado- 
lescent deaths  and  injuries  from  firearms  in  Loui- 
siana. What  is  the  magnitude  of  this  problem? 
Nationally,  firearm  discharges  kill  almost  as 
many  people  each  year  in  the  United  States  as 
do  motor  vehicle  crashes.  Firearm  deaths  and 
death  rates  reached  a 30-year  high  in  1993  (39,595 
deaths).  They  particularly  affect  teens  and  young 
adults  (18,003  in  1995,  mainly  homicides)  and 
the  elderly  (mainly  suicides).  Suicides  are  actu- 
ally the  cause  of  a greater  percentage  of  deaths 
than  homicides  (51%  to  43%).  About  3%  of 
deaths  were  unintentional  in  1995.  An  interna- 
tional comparison  of  26  industrialized  countries 


J La  State  Med  Soc  VOL  152  October  2000  523 


Adolescent  Violence 


found  that  the  firearm  death  rate  for  US  chil- 
dren younger  than  15  years  was  nearly  12  times 
higher  than  among  children  in  the  other  25  in- 
dustrialized countries  combined.1 

Financial  costs  are  also  high.  A best  estimate 
is  that  about  100,000  people  are  shot  but  not 
killed  each  year,  usually  by  handguns.  The  av- 
erage acute  care  cost  of  treating  one  pediatric 
firearm  victim  in  1993  was  about  $15,000.  The 
lifetime  cost  is  estimated  to  average  $191,000  per 
firearm  injury  survivor.  The  nation's  cost  is  up 
to  $112  billion  annually  for  all  firearm  deaths  and 
injuries.  In  one  Seattle  study,  more  than  1/3  of 
all  hospital  charges  were  paid  by  public  payers, 
1/4  by  private  insurance,  the  rest  unpaid.2 

In  Louisiana,  firearm  injuries  are  the  num- 
ber one  mechanism  of  injury  death  and  the  sev- 
enth leading  cause  of  death,  41%  by  suicide,  53% 
by  homicide,  and  6%  unintentional.  Incidences 
occur  in  61  of  the  64  parishes.  The  number  of 
firearm  related  deaths  in  1998  among  males  was 
691  (84%),  females  136  (16%).  Firearm  related 
deaths  were  almost  equal  among  whites  (51%) 
and  blacks  (48%).  Black  males  were  more  likely 
to  be  a victim  of  a firearm  related  death  than 
any  other  group  (43%),  followed  by  white  males 
(40%),  white  females  (11%),  and  black  females 
(5%).  Thirty-two  percent  of  firearm  related 
deaths  occurred  among  the  1-24  year  old  age 
group.  Thirty-eight  percent  of  individuals  older 
than  18  who  died  from  firearms  had  not  com- 
pleted high  school.3  In  1996,  Louisiana  led  the 
nation  in  firearm  death  rates.4 

How  do  numbers  such  as  these  affect  our  citi- 
zens? On  July  31,  2000,  the  Office  of  Public 
Health  released  a report  on  perceptions  of  vio- 
lence in  Louisiana.  This  report  reviews  the  re- 
sults of  a statewide  telephone  survey  discussed 
at  greater  length  later  in  this  paper.  In  spite  of 
declining  rates  of  homicide,  half  of  the  partici- 
pants believed  that  violence  is  a big  problem  in 
their  community,  and  one  in  three  felt  the  prob- 
lem was  growing  worse.  In  the  12  months  prior 
to  the  interview,  about  6 percent  of  participants 
reported  actually  being  physically  assaulted. 
Nearly  1 / 3 of  Louisianans  know  someone  who 


was  a victim  of  physical  or  sexual  violence  in 
the  last  year.  One  third  of  those  people  were  a 
family  member  or  relative.5  Recent  experience 
with  violence  personally  or  by  a family  member 
or  acquaintance  is  a risk  factor  in  unsafe  gun  stor- 
age practices.6 

Assuming  the  problem  is  important,  how  do 
we  go  about  looking  for  solutions?  Who  do  we 
blame?  The  suspects  include  children  and  youth, 
parents,  working  mothers,  general  moral  de- 
cline, media,  schools,  government,  elected  offi- 
cials, healthcare,  gun  manufacturers,  the  Na- 
tional Rifle  Association,  the  criminals.  What  is 
the  best  approach? 

Injuries  occur  when  energy  is  transferred. 
The  Haddon  Matrix  is  a useful  tool  for  locating 
possible  phases  of  energy  transfer:  pre-injury,  in- 
jury, and  post  injury.  It  also  divides  possible 
causes  into  human,  agent,  and  environment.7 
Table  1 is  a matrix  for  child /adolescent  gun 
deaths  and  injuries.  The  same  matrix  may  be 
used  for  any  kind  of  injury,  be  it  motor  vehicle 
accident,  burn,  or  head  injury  from  a baby 
walker.  Readers  may  think  of  other  causes  to  add 
to  this  particular  matrix. 

In  our  experiment,  let  us  consider  those 
causes  that  are  most  amenable  to  change  by  phy- 
sicians. Things  we  can  detect  or  affect  (not  nec- 
essarily change  but  help  the  individual  to  cope) 
include  gun  ownership,  storage  and  type  of  gun, 
substance  use  and  abuse,  history  of  victimiza- 
tion, personal  problems  and  psychiatric  illness 
of  child  and  family,  how  children  are  cared  for 
during  non-school  hours,  exposure  to  media, 
family  violence,  general  condition  of  host,  speed 
of  transport  to  and  quality  of  emergency  care, 
and  rehabilitation. 

As  physicians  we  are  also  citizens.  As  citi- 
zens we  are  a group  that  does  speak  with  a voice 
of  authority  on  health  matters  and  may  have  an 
effect  on  community  attitudes  toward  owner- 
ship and  storage,  treatments  available  for  psy- 
chological problems,  availability  and  use  of  dif- 
ferent types  of  guns  and  safety  features  such  as 
gun  locks,  funding  for  schools,  after  school  pro- 
grams, emergency  medical  response,  and  crisis 


524  J La  State  Med  Soc  VOL  152  October  2000 


Adolescent  Violence 


Table  1 . The  Haddon  Matrix  for  child  and  adolescent  firearm  injuries  and  deaths  in  Louisiana 

Human 

Agent 
and  Carrier 

Environment 

Physicial 

Environment 

Social 

Pre-event 

Gun  ownership ; 

Easily  available 

Place  to  store  firearm 

Media;  lack  of  after 

age,  sex,  race;  SES; 

handgun  without 

-how  easy  is  it  to 

school  supervision] 

Will  a person 

single  parent  family; 

safety  lock  or  other 

obtain  a loaded  gun, 

poor  job  prospects; 

get  a gun  and 

alcohol  or  other 

protective  feature 

unloaded  gun  and 

poor  schools; 

shoot 

substance  use  and 

such  as 

bullets  at  home, 

programs  for 

another 

intoxication-,  curiosity 

personalized 

neighborhood  - how 

delinquent  children; 

person  or 

and  mobility  of  young 

weapon; 

easy  it  is  to  get  a gun 

gangs;  family 

themselves? 

child;  concrete 
operational  thinking  of 
adolescent;  history  of 
victimization  to  self, 
friend  or  family;  school 
failure;  illiteracy; 
unknown  or  untreated 
psychological 
problems 

type  of  gun 

other  than  at  home; 
Urban  or  rural  area 

arguments;  crack; 
Advice  or  lack  of 
advice  given  by 
authority  figures] 
Community 
attitudes  toward 
gun  ownership  and 
storage 

Event 

Susceptibility  to  tissue 

Bullet  size  and  type; 

Location  of  incident; 

Time  of  day; 

damage 

gun  type;  rounds 

school  metal  detectors; 

individuals  present; 

Will  a 
person  be 
shot? 

able  to  be  fired 

alcohol  outlets 

concealed  carry 
permits;  police 
presence  in  the 
community 

Post  event 

Condition  of  host 

Single  or  multiple 

Proximity  to 

Emergency 

(size,  age,  general 

shots  (automatic, 

emergency  medical 

medical  response; 

Will  an  injury 

health,  ability  to  adapt 

semi  automatic 

care;  Ease  of  rapid 

availability  of 

or  death 
occur? 

to  rehab);  body 
part(s)  affected 

guns) 

transport  to  that  care 

rehab]  family  and 
community 
support]  if  victim 
alone  or  someone 
available  to  seek 
help 

Items  in  italics  are  those  more  amenable  to  change. 


J La  State  Med  Soc  VOL  152  October  2000  525 


Adolescent  Violence 


planning  in  our  schools.  For  example,  the  Loui- 
siana State  Medical  Society's  Ad  Hoc  Commit- 
tee on  Children,  Adolescents,  and  Violence  re- 
cently heard  a report  from  the  Louisiana  Attor- 
ney General's  office  about  a joint  effort  with  the 
State  Department  of  Education  in  the  area  of  cri- 
sis planning  in  schools.  They  were  requesting 
our  support. 

How  then  do  you  choose  what  action  to  take? 
Possible  interventions  are  many.  I classify  them 
into  legislative /regulatory,  technical,  educa- 
tional, and  economic.  A partial  list  includes: 

For  legal/regulatory/policy  they  include  a 
handgun  ban;  licensing  and  registration;  further 
restriction  on  sales;  the  Department  of  Alcohol, 
Tobacco  and  Firearms  (ATF)  tracing  of  guns  used 
in  youth  crimes  with  increased  penalties  for 
straw  purchasers  and  traffickers;  increasing  the 
age  of  legal  purchase  and  or  use  of  firearms;  and 
the  banning  of  gun  shows,  or  at  least  the  regula- 
tion of  purchases  in  these  shows. 

For  technical  they  include  the  so  called  "safe 
guns",  guns  which  can  fire  only  when  the  owner 
wears  a special  ring  or  the  owner  fingerprint  is 
detected;  automatic  safety  locks  on  guns;  im- 
provements on  storage  mechanisms;  metal  de- 
tectors in  schools;  and  increased  psychiatric 
medication  for  youth  who  are  violent  or  failing 
in  school. 

For  educational/behavioral  possible  interven- 
tions are  peace  officer  training  to  discourage  un- 
safe storage;  physician  counseling  on  safe  stor- 
age or  ownership  of  guns;  intensive  focused  in- 
terventions on  first  time  youth  offenders;  more 
drug  use  prevention  in  schools;  more  home  vis- 
iting programs  for  high-risk  mothers  and  their 
babies;  and  intensive  educational  and  social  in- 
terventions in  children  who  exhibit  violent  be- 
haviors or  school  failure. 

For  economic  interventions  the  list  includes 
gun  buy  backs;  homeowner  insurance  reduction 
for  homes  without  guns;  discounted  safety  de- 
vices; and  even  legalization  of  what  are  now  il- 
legal drugs  to  decrease  the  need  for  cash  and  a 
criminal  network  to  obtain  the  drugs. 

Even  this  partial  list  of  options  is  quite  di- 
verse. To  narrow  our  choices  I choose  a phase 


(pre,  post,  or  injury)  at  which  to  intervene.  Be- 
cause of  the  potentially  devastating  effects  of 
firearm  use  even  with  the  best  of  medical  care,  I 
will  look  exclusively  at  the  pre-injury  phase  and 
have  chosen  six  interventions  to  consider.  I am 
sure  the  reader  can  think  of  others.  The  six  I have 
chosen  are  gun  tracing  in  youth  crime,  safe  gun 
technology,  gun  buy  backs,  and  three  in  the  area 
of  education  and  behavior,  focus  on  juvenile  of- 
fenders, high-risk  new  mothers,  and  office-based 
firearm  storage  counseling.  Even  with  this  lim- 
ited menu,  how  would  we  choose? 

To  help  us  we  have  another  useful  tool,  the 
Intervention  Decision  Matrix  developed  at  the 
Johns  Hopkins  Center  for  Injury  Research  and 
Policy.8  Please  refer  to  Table  2.  This  matrix  out- 
lines the  factors  we  need  to  take  into  account 
when  choosing  an  intervention.  It  is  important 
to  remember  the  obvious.  Resources  are  limited. 
Any  funds  spent  on  one  option  will  not  only 
diminish  funds  available  for  another,  but  may 
also  diminish  political  and  social  will  if  an  in- 
tervention is  ineffective.  Even  if  an  intervention 
is  politically  acceptable,  inexpensive,  sustain- 
able, and  easy  to  do,  is  it  worth  doing  if  it  is  not 
effective?  The  following  discussion  covers  the 
six  selected  interventions. 

Legal/regulatory/policy  option:  The  Bureau  of 
Alcohol,  Tobacco,  and  Firearms  (ATF)  tracing  of 
guns  used  in  youth  crimes.  Youth  get  their  fire- 
arms from  different  sources.  One  is  at  home.  I 
discuss  home  storage  under  education.  But 
youth  also  get  their  guns  away  from  home.  In 
1996,  President  Clinton  initiated  the  Youth  Crime 
Gun  Interdiction  Initiative  (YCGII).  One  effort 
of  this  initiative  has  been  to  analyze  the  source 
of  guns  to  youth  in  27  cooperating  cities.  Accord- 
ing to  the  ATF  "When  YCGII  began,  many  law 
enforcement  officials  believed  most  juvenile  and 
youth  offenders  stole  their  crime  guns. . . through 
YCGII's  comprehensive  tracing  [they]  have 
shown  that  illegal  gun  market  activity  is  an  im- 
portant element  of  crime  gun  acquisition  by  ju- 
veniles and  youth".9  What  is  this  market?  It  is 
primarily  the  use  of  straw  purchasers,  the  use 
of  someone  to  buy  a gun  for  a person  who  is 
prohibited  from  doing  so.  Some  of  the  guns  used 


526  J La  State  Med  Soc  VOL  152  October  2000 


Adolescent  Violence 


at  Columbine  High  School  were  purchased  this 
way.  Using  this  tracing  system,  the  Bureau  of 
ATF  has  found  that  more  than  half  of  the  guns 
criminals  use  are  purchased  from  federally  li- 
censed firearm  dealers. 

This  option  has  possible  long-term  effective- 
ness because  it  casts  light  on  access  to  firearms, 
a major  issue  in  youth  firearm  injuries,  and  could 
potentially  lead  to  effective  policy  change.  The 
findings  from  the  YCGII  study  done  in  Boston, 
for  example,  were  used  to  target  suspect  deal- 
ers, traffickers,  and  straw  purchasers.  One  re- 
sult is  that  only  one  juvenile  has  been  killed  in 
Boston  by  a handgun  in  the  last  2 years.  Its  ef- 
fectiveness, however,  depends  upon  the  willing- 
ness of  a society  to  utilize  the  information  ob- 
tained. Congress,  for  example,  has  failed  to  ban 
straw  purchases  and  allows  the  bureau  to  inspect 
a dealer's  records  only  once  a year.  The  bureau 
also  cannot  send  undercover  agents  posing  as 
felons  to  buy  guns,  cannot  maintain  a comput- 
erized record  of  gun  sales,  and  cannot  regulate 
private  sales  at  gun  shows  or  elsewhere.10  This 
is  why  I have  chosen  moderate  for  all  classifica- 
tions. It  is  feasible,  that  is  to  say  possible,  to  carry 
out  the  study  statewide  if  there  is  the  political 
will  and  the  legislature  will  fund  it.  Or  the  study 
can  be  done  at  the  community  level.  Most  of  the 
ATF  YCGn  coalitions  were  in  cities,  not  entire 
states.  Possible  unintended  consequences  may 
be  positive,  with  the  enactment  of  effective  leg- 
islation, or  negative,  funding  shifts  from  other 
essential  programs. 

TECHNICAL: 

SAFE  GUN  TECHNOLOGY 

Safe  gun  technology  has  been  available  for  al- 
most a century,  and  it  is  effective.  However,  it 
has  not  yet  been  developed  for  the  mass  mar- 
ket. An  unintended  consequence  might  be  the 
increased  price  of  new  guns. 

Educational/Behavioral 

1)  Focused  interventions  on  juvenile  offenders.  Pro- 
grams that  are  touted  as  successful  focus 
multidisciplinary  efforts  on  the  few  repeat  of- 


fenders. This  allows  for  greater  intensity  and 
specificity  of  effort  when  compared  to  interven- 
tions aimed  at  the  general  public.  However,  are 
they  effective?  An  evaluation  of  youth  handgun 
programs  based  in  communities  was  carried  out 
by  the  Center  for  the  Study  and  Prevention  of 
Violence  in  Boulder,  Colorado.  A review  of  163 
programs  showed  only  three  programs  with 
positive  evaluations  and  two  of  those  had  no 
comparison  groups,  which  left  the  evaluations 
in  doubt.11  The  National  Center  for  Injury  Pre- 
vention and  Control  is  presently  funding  evalu- 
ation of  community  programs.  An  unintended 
consequence  of  focused  interventions  might  be 
the  increased  scholastic  success  of  one  group  to 
the  detriment  of  another. 

2)  Early  interventions  in  high-risk  families. The  state 
Office  of  Mental  Health  funds  a high-risk  first 
mother  visiting  program.  An  article  in  a publi- 
cation by  the  state  Department  of  Public  Safety 
and  Corrections,  February  2000,  cites  the  "Syra- 
cuse Family  Development  Research  program 
showing  that  delinquency  was  reduced  by  91% 
when  families  were  provided  with  parent  train- 
ing, home  visits,  training  on  safety  issues,  and 
other  human  services  beginning  during  the  pre- 
natal period  and  continuing  until  children 
reached  elementary  age."12  However,  these  pro- 
grams are  no  panacea  and  evaluations  have  not 
shown  them  to  be  as  successful  as  the  Syracuse 
data  would  suggest.13  Also,  to  have  a significant 
effect,  this  effort  would  require  funding  over  a 
long  period  and  at  a high  level.  Louisiana  has 
many  mothers  and  babies  at  risk.  The  1999  Annie 
E.  Casey  Kids  Count  report,  which  is  based  on 
1997  data,  states  that  Louisiana  ranks  fiftieth  in 
the  US  in  conditions  for  children.14 

Also  at  issue  is  the  problem  that  this  ap- 
proach will  not  give  quick  results  because  it  is 
so  indirect.  It  will  take  a great  deal  of  ongoing 
public  education  to  ensure  sustained  support. 
The  positive  unintended  consequences  might  be 
increased  success  not  only  for  the  child  but  also 
its  mother  and  other  siblings. 

3)  Office  based  counseling  on  gun  storage  practices. 
Dr  Megan  Davies  presented  a review  of  unsafe 


J La  State  Med  Soc  VOL  152  October  2000  527 


Adolescent  Violence 


firearm  storage  practices  in  Louisiana  at  the 
Centers  for  Disease  Control  (CDC)  in  February 
of  this  year.  She  was  kind  enough  to  share  her 
analysis.  She  and  colleagues  analyzed  data  from 
a random  digit  dial  telephone  survey  on  gen- 
eral risk  behavior  assessment  telephone  survey 
done  by  the  Louisiana  Office  of  Public  Health 
from  July  1998  to  June  1999.  Of  the  108  ques- 
tions on  the  survey,  four  were  on  firearms.  Re- 
sponse was  34%  male,  65%  female,  73%  white, 
58%  urban,  47%  with  education  over  12  years, 
and  47%  with  income  greater  or  equal  to  $25,000. 
Thirty-four  percent  of  gun  owners  stored  their 
guns  loaded.  Forty-seven  percent  stored  them 
unlocked.  Twenty-two  percent  stored  them  both 
unlocked  and  loaded.  Unsafe  storage  (either 
unlocked  or  loaded  or  both),  by  presence  of  chil- 
dren in  households  with  guns,  indicated  11% 
with  children  under  5 years  old,  11%  ages  5 to  12, 
14%  ages  13  tol7,  and  27%  with  no  children. 
They  analyzed  gun  ownership  and  storage  by 
experiences  with  violence.  They  found  that  53% 
of  households  had  guns,  22%  stored  them 
unsafely,  56%  of  households  with  children  had 
guns  and  12%  of  these  households  stored  them 
unsafely.  There  was  a higher  prevalence  of  un- 
safe storage  in  households  that  were  white,  ur- 
ban, higher  income,  and  respondent  not  mar- 
ried. As  mentioned  before,  prevalence  was  also 
higher  when  the  respondent  felt  unsafe  at  work, 
knew  a recent  victim  of  violence,  had  been  a re- 
cent victim  of  violence,  had  been  stalked,  or  had 
been  sexually  assaulted.15 

Clearly,  many  households  in  Louisiana  place 
the  children  in  those  households  at  risk  due  to 
improper  firearm  storage.  Both  the  American 
Academy  of  Pediatrics  and  the  American  Acad- 
emy of  Family  Physicians  support  prevention- 
screening programs  in  firearm  storage  practices. 
These  programs  include  brochures  and  screen- 
ing questionnaires.  I reviewed  the  literature  in 
primary  care  screening  practices  in  1999  and 
found  that  counseling  is  the  exception  rather 
than  the  rule.  Generally  fewer  than  15%  of  pri- 
mary care  physicians  who  care  for  children  re- 
port routinely  screening  for  firearm  storage.  The 
main  reasons  given  for  lack  of  screening  are  lack 


of  time  or  expertise  and  a concern  that  they 
would  alienate  parents.  In  a study  done  by  the 
Harrisburg  Area  Research  Network,  a Pennsyl- 
vania organization  of  family  physicians, 
Shaughnessy  and  colleagues  review  the  litera- 
ture with  the  same  results.  They  also  question 
whether  office-based  physician  firearm  safety 
efforts  have  the  potential  to  be  effective.  They 
found  that  family  physicians  lack  credibility  in 
the  eyes  of  their  patients  and  most  gun  owners 
did  not  think  they  would  follow  their  physicians' 
advice  about  firearm  storage.16  Clearly  this  ap- 
proach needs  further  evaluation. 

ECONOMICALLY  DRIVEN: 

GUN  BUY  BACKS 

Gun  buy  backs  have  not  been  shown  to  be  effec- 
tive.17 The  US  Department  of  Housing  and  Ur- 
ban Development  is  presently  sponsoring  gun 
buy  backs  on  a large  scale.  We  await  the  results 
of  an  evaluation  of  this  program.  An  obvious  un- 
intended consequence  is  the  potential  unload- 
ing of  guns  previously  used  in  criminal  acts  as 
well  as  the  use  of  funds  obtained  to  purchase 
new  firearms. 

Clearly  there  is  no  easy  answer.  Louisiana 
has  had  no  school  shooting,  but  the  school 
shootings  are  the  exception,  not  the  rule.  Chil- 
dren are  actually  safer  at  school  than  at  home  or 
on  the  streets.  Less  than  1 percent  of  all  homi- 
cides among  school-aged  children  occur  in  or 
around  school  grounds  or  on  the  way  to  and 
from  school.18  There  is  higher  risk  in  the  neigh- 
borhood and  at  home  where  the  suicidal  person 
is  five  times  more  likely  to  complete  his  suicide 
attempt  if  there  is  a gun  in  the  home.19  Is  the 
law  and  regulation  the  answer?  The  preliminary 
data  from  the  ATF  gun  tracking  studies  men- 
tioned above  would  indicate  that  the  many  laws 
that  do  exist  to  regulate  firearms  do  not  form  a 
comprehensive  system  to  prevent  purchase  of 
firearms  by  felons. 

Garen  Wintemute,  in  a review  of  firearm  pre- 
vention efforts,  reviews  what  the  research  has 
shown  to  be  effective.  This  includes  (1)  focusing 
on  specific  neighborhoods  and  specific  offend- 


528  J La  Stale  Med  Soc  VOL  152  October  2000 


Adolescent  Violence 


Table  2:  Intervention  Decision  Matrix:  Child  and  Adolescent  firearm  injuries  and  deaths  in  Louisiana. 

Strategy  Options 

Legal/Regulatory/ 

Policy 

Technical 

Educational/ 

Behavioral 

Economically 

Driven 

Proposed 

Intervention 

ATF  tracing  of  guns 
used  in  youth 
crimes 

Safe  gun 
technology  - 
Would  require 
some  mandate 

Focused  interventions  on 

1)  Juvenile  offenders 

2)  High  risk  new  mothers 

3)  Office-based 
counseling 

Gun  buy  backs 

Intervention 

Effectiveness 

Moderate 

High 

1 ) Low  to  moderate 

2)  Moderate 

3)  Low  to  moderate  (all 
unevaluated) 

Low 

Intervention 

Feasibility 

Moderate 

Low  in  the  short 
term 

1 ) Moderate 

2)  Moderate 

3)  Low  to  moderate 

Moderate 

Intervention 

Affordability 

Moderate 

Low  (means  high 
cost) 

1 ) Moderate 

2)  Moderate 

3)  High 

Moderate 

Intervention 

Sustainability 

Moderate 

High  once  achieved 

1 ) Moderate  to  low 

2)  Moderate 

3)  Moderate 

Low 

Political 
Acceptability 
(Includes  ethical) 

Moderate 

Low  due  to 
mandate 

1)  Moderate 

2)  Moderate 

3)  Moderate 

Moderate 

Social  (&  Political) 
Will 

Moderate 

Moderate 

1 ) Moderate 

2)  Moderate 

3)  Moderate 

Moderate 

Possible 

unintended 

consequences 

Moderate 

Moderate 

1)  Moderate 

2)  Moderate 

3)  Moderate 

Moderate 

Priority  rating 

14 

13 

1)  13 

2)  14 

3)  14 

12 

The  author  has  given  high  3 points,  moderate  2 and  low  1 and  averaged  when  both  are  mentioned  in  one  block. 
See  discussion  for  reasons  for  rankings. 


ers,  (2)  tracing  firearms  used  in  crimes  to  iden- 
tify traffickers  and  straw  purchasers,  (3)  decreas- 
ing the  number  of  federally  licensed  firearm 
dealers  (which  have  decreased  from  244,000  in 
1993  to  90,000  in  1998),  and  (4)  restrictions  on 
purchase.  He  states  that  bills  such  as  the  Brady 
Bill,  in  spite  of  not  covering  sales  in  gun  shows, 
have  prevented  70,000  to  80,000  sales  to  felons. 

Wintemute  also  reviews  the  literature  on 
what  may  feel  good  but  hasn't  been  shown  to 
work.  These  are  gun  buy  backs;  child  access  pre- 
vention laws  (the  owner  of  the  gun  is  held  re- 
sponsible for  crimes  committed  by  a child  us- 
ing that  gun)  unless  associated  with  a felony 
penalty;  Eddie  Eagle  (a  NRA  sponsored  child 


education  program);  and  concealed  carry. 

His  recommendations  focus  on  the  seller,  the 
purchaser,  and  the  manufacturer.  For  the  seller: 
increase  disincentives  for  trafficking  by  tracing 
guns  used  in  crimes,  shut  down  straw  purchas- 
ers, pass  a national  one  gun  a month  law,  and 
prosecute  the  1%  of  dealers  who  sell  most  of  the 
guns  involved  in  crime.  For  the  purchaser:  do 
more  to  keep  the  wrong  people  from  purchas- 
ing. About  40%  of  sales  do  not  occur  in  gun 
stores.  Also,  he  recommends  including  selected 
misdemeanor  convictions  along  with  felonies  to 
exclude  individuals  from  being  able  to  purchase 
a firearm.  This  group  is  six  times  more  likely  to 
commit  a crime.  Finally  he  focuses  on  the  manu- 


J La  State  Med  Soc  VOL  152  October  2000  529 


Adolescent  Violence 


facturers  and  the  gun.  This  proved  to  be  a suc- 
cessful approach  in  motor  vehicle  injury  reduc- 
tion. He  also  mentions  personalized  weapons  as 
mentioned  above.  Ninety-three  percent  of  gun 
owners  favor  design  performance  standards.20 
In  fact,  most  gun  owners  support  what  some 
have  called  "the  anti-gun  agenda".  Sixty-six  per- 
cent of  gun  owners  support  background  checks 
on  all  purchases,  including  private  gun  sales. 
Eighty-two  percent  support  mandatory  back- 
ground check  and  five-day  waiting  period  for 
handguns.  Eighty-one  percent  would  require  all 
new  handguns  to  be  childproof.21 

A comparison  to  motor  vehicle  injury  reduc- 
tion efforts  shows  an  approach  to  injury  preven- 
tion that  has  been  successful.  Table  3 lists  some 
of  the  efforts  required  to  reduce  motor  vehicle 
injury  rates.  Surveillance,  regulation,  research, 
a national  data  bank,  incentives  to  states  to  com- 
ply with  regulation,  all  were  part  of  the  dramatic 
decrease  in  motor  vehicle  injury  deaths  seen  be- 
tween 1950  and  1995.22 

Louisiana  was  one  of  the  first  states  in  the 
nation  where  injury  deaths  from  firearms  sur- 
passed those  from  motor  vehicle  accidents.  Ef- 
fective action  will  be  expensive  and  politically 
difficult.  However,  to  speak  about  violence  and 
our  youth  and  not  speak  of  firearm  access  is  to 


put  our  heads  in  the  sand.  Littleton,  Paducah, 
Jonesboro,  Springfield,  and  the  others  did  not 
happen  with  knives,  fists,  or  baseball  bats. 

RESOURCES 

1.  Bonnie  RJ,  Fulco  CE,  Liverman  CT  (editors). 
Reducing  the  Burden  of  Injury.  Washington,  DC: 
National  Academy  Press;  1999:  124. 

2.  Christoffel,  KK.  1997  HELP  Conference  -Cost  Presen- 
tation. Available  at:  http://www.childnnc.edu/ 
help/KKC.htm  [viewed  March  1999] 

3.  Louisiana  Office  of  Public  Health.  1998  Fact  Sheet 
on  Firearms.  New  Orleans,  La:  Office  of  Public 
Health,  Department  of  Health  and  Hospitals;  June 
30,  2000. 

4.  Violence  Policy  Center.  Who  dies  ? A Look  at  Firearms 
Death  and  Injury  In  America  - Revised  Edition. 
Available  at  http:  / / www.vpc.oig  / studies  / whostate.htm 
[Accessed  in:  August  2000] 

5.  State  of  Louisiana,  Department  of  Health  and  Hos- 
pitals Bureau  of  Communications  and  Inquiry  Ser- 
vices. Violence  is  Local  Problem  says  Report.  Available 
at:  http:  / / www.dhh.state.la.us/NEWS/Violence.htm 
[Accessed  in:  August  2000] 

6.  Davies  M,  Kohn  M,  Flood  H.  Experiences  of  Vio- 
lence and  Storage  of  Firearms  - Louisiana,  1998 
[Abstract].  49th  Annual  Epidemic  Intelligence  Ser- 
vice Conference.  2000;45. 

7.  Scutchfield  FD,  Keck  CW.  Principles  of  Public  Health 
Practice.  New  York,  NY:  International  Thomson 
Publishing;  1997:340. 


Table  3:  Motor  Vehicle  Injury  Reduction:  What  was  done? 


Surveillance 

Fatality  Injury  Reporting  System  and  others 
Linking  of  data:  police  report  and  hospital 
Assessment  of  the  effects  of  legislation 

Regulation  and  Legislation 

1966  - National  Highway  Traffic  and  Motor  Vehicle  Safety  Act 
- Highway  Safety  Act 

1967  - national  standards  for  education,  licensing,  alcohol  countermeasures 
1970  - vehicle  safety  standards 

Research  on  effects  of  interventions 

Driver/occupant  - increased  penalties  for  drunk  driving:  national  standards  for  education,  licensing:  speed  limits 
Vehicle  - passive  restraints,  improved  brakes,  lights,  tires,  etc. 

Environment  — speed  limits,  roadway  design,  breakaway  pole,  guard  rails 

(Institute  of  Medicine,  Reducing  the  Burden  of  Injury,  National  Academy  Press,  1999) 


530  J La  State  Med  Soc  VOL  1 52  October  2000 


Adolescent  Violence 


8.  Fowler,  CJ,  Dannenberg,  AL.  Intervention  Decision 
Matrix.  Baltimore,  Md:  The  Johns  Hopkins  Center 
for  Injury  Research  and  Policy;  1997. 

9.  Bureau  of  Alcohol,  Tobacco,  and  Firearms.  ATF:  The 
Youth  Crime  Gun  Interdiction  Initiative , Crime  Gun 
Trace  Analysis  Reports:  The  Illegal  Youth  Firearms 
Market  in  27  Communities.  Department  of  the 
Treasury,  Bureau  of  Alcohol,  Tobacco,  and  Firearms, 
Washington  DC:  United  States  Department  of  the 
Treasury;  1999. 

10.  Butterfield  F.  Guns:  The  law  as  selling  tool.  The  New 
York  Times,  Sunday  August  13,  2000:  4 wk. 

11.  Karjicek,  JD.  Anti-gun  youth  programs  shoot 
blanks,  funder  seeks  new  tactics.  Youth  Today  2000 ;7: 
44. 

12.  Corrections  Services.  Controlling  the  Growth  of 
Incarceration  in  Louisiana.  Baton  Rouge,  La: 
Louisiana  Department  of  Public  Safety  and 
Corrections;  2000. 

13.  Gomby  DS,  Culross  PL,  Behrman  RE.  Home 
visiting:  recent  program  evaluations  - analysis  and 
recommendations.  In:  Behrman  RE  (editor).  Home 
Visiting:  Recent  Program  Evaluations.  Los  Altos,  Calif: 
The  David  and  Lucile  Packard  Foundation;  1999:4- 
26. 


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14.  King  K.  Survey:  Conditions  for  La.'s  children  rank 
last  in  nation.  Available  at:  www.theadvocate.com  / 
news/  story.asp?StoryID==14077  [Accessed  in  June2000j. 

15.  Davies  M,  Kohn  M,  Flood  H.  Unsafe  Firearm  Storage 
and  Experiences  of  Violence,  Louisiana,  1998.  Report 
given  at  the  Epidemic  Intelligence  Service,  Centers 
for  Disease  Control,  Atlanta,  Ga;  February,  2000. 

16.  Shaughnessy  AF,  Cincotta  JA,  Adelman  A.  Family 
practice  patients'  attitudes  toward  firearm  safety  as 
a preventive  medicine  issue:  a HARNET  study.  / 
Am  Bd  Fam  Prac  1999;12:  354. 

17.  Wintemuth  GJ,  The  future  of  firearm  violence 
prevention:  building  on  success.  JAMA  1999; 
282:475-478. 

18.  Kachur  SP,  Spennies  GM,  Powell  KE,  et  al.  School- 
associated  violent  deaths  in  the  United  States,  1992 
to  1994.  JAMA  1996;275:1729-1733. 

19.  Kellerman  A.  Suicide  in  the  home  in  relation  to  gun 
ownership.  N Engl  J Med  1992;  327:476-481. 

20.  Wintemute  GJ.  The  future  of  firearm  violence 
prevention,  building  on  success.  JAMA  1999:475- 
480. 

21.  National  Opinion  Research  Center.  Report:  1998 
National  gun  Policy  Survey.  Chicago,Il:  University 
of  Chicago;  1999. 

22.  Bonnie  RJ,  Falcon  CE,  Liveryman  CT  (editors). 
Reducing  the  Burden  of  Injury.  Washington,  DC: 
National  Academy  Press;  1999:116. 


Dr  Galland  is  Associate  Professor,  Clinical  Family  Medicine, 
at  Louisiana  State  University  Health  Sciences  Center  and 
Earl  K.  Long  Medical  Center  in  Baton  Rouge,  Louisiana. 


J La  State  Med  Soc  VOL  152  October  2000  531 


alendar 


October  2000 


November  2000 


12-14  Annual  Clinical  Conference  of  the  World 
Foundation  for  Medical  Studies  in 
Female  Health 

New  Orleans,  La.  Contact  (516)  944-7340. 

19-21  Academy  of  Surgical  Research  16th 
Annual  Meeting 

Cincinnati,  Ohio.  Contact  (800)  98-ARDEL. 

21-24  Medical  Group  Management  Association 
(MGMA)  Annual  Conference  and  Section 
Conferences 

San  Antonio,  Tex.  Contact  (303)  799-1111. 


1-3  NIH  Consensus  Development  Conference 
“Adjuvant  Therapy  for  Breast  Cancer” 
Bethesday,  Md.  Contact:  (301)  592-3320. 

11  American  Diabetes  Association’s 

“America’s  Walk  for  Diabetes” 

Downtown  Baton  Rouge,  La. 

Contact  (225)  292-6005. 

18  American  Heart  Association’s 

“2000  American  Walk” 

New  Orleans,  La.  Contact  (800)  AHA-USA1 . 


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532  J La  State  Med  Soc  VOL  152  October  2000 


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Of  the  Louisiana  State  Medical  Society 


HS/HSL 

UNIVERSITY  OF  MARYLAND  AT 

BALTIMORE 


Percutaneous  Recanalization  of  Thrombosed  Dialysis  Shunts 


Synovial  Cyst  of  Lumbar  Spine  Presenting  as  Disc  Disease:  A Case  Report  and  Review  of  Literature 
Higher  Risk  of  HIV  Transmission  During  Trauma  Resuscitations 


A Prescription  for  the  21st  Century:  T.E.A.C.H.  Our  Patients 


ECG  of  the  Month:  Pay  Close  Attention 

Otolaryngology/Head  and  Neck  Surgery  Report  of  the  Month:  Congenital  Nasal  Pyriform  Aperture  Stenosis 
Radiology  Case  of  the  Month:  Congenital  Limb  and  Bleeding  Disorder 
History  of  Medicine:  Preparation  for  and  Description  of  the  Cesarean  Section 


powerful  gradients  currently  approved  by  the 
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angiography.  Medicare  now  provides 
coverage  and  has  approved  MRA 
as  an  appropriate  test  in  determining 
the  extent  of  peripheral  vascular 
disease  in  the  lower  extremities* 
Additionally,  MRA  has  been  shown  to  find 
occult  flow  in  blood  vessels  where  it  was  not 
apparent  on  conventional  angiography. 

MRA  is  a non-invasive  test  and  requires 
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ESTABLISHED  1844,  Owned  and  edited  by  the 
Journal  of  the 
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Copyright  2000  by  the  Journal  of  the 
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The  Journal  of  the  Louisiana  State  Medical  Society 

(ISSN  0024-6921)  is  published  monthly 
at  6767  Perkins  Road,  Louisiana  State  Medical  Society, 
Baton  Rouge.  LA  70808. 
Periodical  postage  paid  at  Baton  Rouge,  LA 
and  additional  mailing  offices. 


Articles  and  Advertisements  published  in  the  Journal 
are  for  the  interests  of  its  readers  and  do  not 
necessarily  represent  the  official  position  or 
endorsement  of  the  Journal  of  the  Louisiana 
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Louisiana  State  Medical  Society. 


The  Journal  reserves  the  right  to  make  the  final 
decision  on  all  contents  and  advertisements. 


■*  i tCi 

.ES 

Chun  Wang  Tan,  MD 

559 

Percutaneous  Recanalization 

Royce  Dean  Yount,  MD 

of  Thrombosed  Dialysis  Shunts 

Roberto  E.  Quintal  MD,  PhD 

Praveen  Reddy,  MD 

563 

Synovial  Cyst  of  Lumbar  Spine 

Satish  Satyanarayana,  MD 

Presenting  as  Disc  Disease: 

Anil  Nanda,  MD 

A Case  Report  and  Review  of  Literature 

Atul  K.  Madan,  MD 

567 

Higher  Risk  of  HIV  Transmission 

Kelly  J.  McKinell,  MPH 

During  Trauma  Resuscitations 

Stephanie  J.  Posner,  MPH 
C.  Greg  Gaines,  PhD 
Lewis  M.  Flint,  MD 

Daniel  R.  Bronfin,  MD 

572 

A Prescription  for  the  21st  Century: 
T.E.A.C.H.  Our  Patients 

Depart 

540 

INFORMATION  FOR  AUTHORS 

Jorge  1.  Martinez-Lopez,  MD 

543 

ECG  OF  THE  MONTH 
Pay  Close  Attention 

James  P.  Lacey,  MD,  MPH 

546 

OTOLARYNGOLOGY/HEAD  & NECK 

Karla  Brown,  MD 

SURGERY  REPORT 

Congenital  Nasal  Pyriform  Aperture  Stenosis 

Colleen  M.  Costelloe,  MD 

551 

RADIOLOGY  CASE  OF  THE  MONTH 

Edward  H.  De  Mouy,  MD 

Congenital  Limb  and  Bleeding  Disorder 

Harold  R.  Neitzschman,  MD 

Gustavo  Colon,  MD 

553 

HISTORY  OF  MEDICINE 
Preparation  for  and  Description  of 
the  Cesarean  Section 

576 

CALENDAR 

578 

CLASSIFIED  ADVERTISING 

J La  State  Med  Soc  VOL  152  November  2000  539 


Information  for  Authors 


The  Journal  is  published  for  the  benefit  of  the  members  of  the  Louisiana  State 
Medical  Society.  Manuscripts  should  be  of  interest  to  a broad  spectrum  of  phy- 
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reference  to  an  article  in  a journal,  (2)  a reference  to  a book  or  monograph, 
and  (3)  a reference  to  a part  of  a larger  work. 

1.  Brush  JE  Jr,  Cannon  RO  III,  Schenke  WH,  et  al.  Angina  due  to  coro- 
nary microvascular  disease  in  hypertensive  patients  without  left  ven- 
tricular hypertrophy.  NEngl  JMed  1988;319:1302-1307. 

2.  Hajdu  SI.  Pathology  of  So  ft  Tissue  Tumors.  Philadelphia,  Pa:  Lea  & 
Febiger;  1979:60-83. 

3.  Robinson  BH.  Lactic  acidemia.  In:  Scriver  CR,  Beaudet  AL,  Sly  WS, 
et  al  (editors).  The  Metabolic  Basis  of  Inherited  Disease,  6th  edition. 
New  York:  McGraw-Hill;  1989:869-888. 

Type  each  reference  entry  as  a separate  hanging  paragraph;  number  the 
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tors. 

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ber the  figures  in  the  order  first  cited  in  the  text. 

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Editor,  Journal  of  the  Louisiana  State  Medical  Society 
6767  Perkins  Rd. 

Baton  Rouge,  LA  70808 


540  J La  State  Med  Soc  VOL  1 52  November  2000 


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542  J La  State  Med  Soc  VOL  152  November  2000 


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ECG  of  the  Month 


Pay  Close  Attention 

Jorge  I.  Martinez-Lopez,  MD 


A 45-year-old  man  presented  at  the  hospital  with  acute  onset  of  severe  retrosternal  tightness,  which 
started  approximately  4 hours  earlier.  The  12-lead  ECG  and  rhythm  strip,  limb  lead  II,  shown 
below  were  recorded  shortly  after  his  arrival. 


What  is  your  diagnosis? 
Elucidation  begins  on  page  544 


J La  State  Med  Soc  VOL  152  November  2000  543 


ECG  of  the  Month 
Presentation  is  on  page  543. 

DIAGNOSIS  - Acute  myocardial  infarction 

The  basic  cardiac  rhythm  is  sinus,  at  88  times  a 
minute.  Both  the  PR  and  the  QRS  intervals  are 
normal  and  reflect  normal  AV  and  intraventricu- 
lar conduction  times,  respectively.  Also  normal 
in  duration  is  the  QT  interval,  a measurement 
that  includes  both  ventricular  depolarization  and 
ventricular  repolarization. 

At  first  glance,  it  is  possible  to  believe  that 
the  tracing  represents  an  example  of  the  so-called 
early  repolarization  pattern  (ERP),  a benign  nor- 
mal variant.  Closer  inspection  of  the  tracing, 
however,  clearly  indicates  that  it  is  not  normal. 
Elevated  ST  segments  are  found  in  limb  leads 
II,  III  and  AVF,  along  with  upright,  tall  T waves 
in  the  same  leads.  Equally  important  is  finding 
that  limb  leads  I and  AVL  display  depressed, 
downsloping  ST  segments  and  inverted  T 
waves;  these  additional  findings  suggest  recip- 
rocal ST-T-wave  changes  and  support  the  infer- 
ence that  ST-segment  elevation  in  the  inferior 
leads  is  due  to  acute  myocardial  injury  or  in- 
farction and  not  due  to  ERP.  Reciprocal  ST-T- 
wave  changes  are  absent  in  " uncomplicated" 
ERP.  Other  ECG  findings  in  ERP  include  early 
precordial  transition,  tall  R waves,  tall  T waves, 
a terminal  slur  in  the  downstroke  of  the  R wave 
(in  some  leads),  and  a stable  ECG  pattern,  when 
a current  ECG  is  compared  with  past  or  subse- 
quent tracings. 

A second  feature  found  on  the  tracing  is 
somewhat  disturbing:  the  questionable  elevation 
of  the  ST  segments  recorded  from  precordial 
leads  V3  through  V6  may  represent  additional 
injury  or  infarction  of  the  anterior  wall  of  the 
left  ventricle.  Were  this  true,  it  would  imply  that 
the  infarction  is  a large  one  and  that  the  risk  of 
complications  and  death  is  higher  than  average. 

Other  conditions  to  consider  in  the  differen- 
tial diagnosis  of  widespread  ST-segment  eleva- 
tion in  patients  who  present  with  acute,  non- 
traumatic,  chest  pain  include  acute  pericarditis 
and  acute  coronary  vasospasm.  It  is  typical  for 


acute  pericarditis  to  present  with  a pleuritic-type 
of  central  chest  pain  and  a pericardial  friction 
rub.  In  contrast  to  acute  myocardial  infarction, 
in  which  the  coronary  occlusion  causes  regional 
ST-T-wave  changes,  elevation  of  the  ST  segments 
is  found  in  all  leads  in  acute  pericarditis,  and 
depression  of  the  PQ  segment  is  often  present 
as  well;  reciprocal  depression  may  or  may  not 
be  found  in  AVR. 

Acute  coronary  vasospasm  is  perhaps  the 
closest  pathologic  ECG  mimic  of  acute  myocar- 
dial infarction.  Because  it  usually  induces  trans- 
mural myocardial  ischemia  or  injury,  ST-segment 
elevation  is  registered  over  the  myocardial  re- 
gion perfused  by  the  spastic  coronary  artery; 
reciprocal  ST-T-wave  changes  are  also  found  in 
areas  remote  from  the  ischemic  or  injured  ven- 
tricular wall.  Prompt  relief  of  the  ischemic  pain 
and  early  normalization  of  the  ECG  usually  fol- 
low the  administration  of  sublingual  or  intrave- 
nous nitroglycerin,  unless  vasospasm  results  in 
myocardial  necrosis  or  previous  tracings  were 
abnormal. 

Taken  together,  the  clinical  presentation  and 
the  ECG  findings  in  this  patient  are  consistent 
with  a diagnosis  of  acute  inferior  myocardial 
infarction.  The  possibility  of  coexisting  anterior 
wall  involvement  was  eliminated  when  subse- 
quent tracings  failed  to  show  any  evolutionary 
changes  of  infarction  in  the  precordial  leads. 

Clinically  significant  right  ventricular  infarc- 
tion is  reported  to  occur  in  about  one  third  of 
cases  with  acute  inferior  myocardial  infarction. 
Because  management  of  "pure"  inferior  infarc- 
tion differs  from  that  of  inferior  infarction  com- 
plicated by  right  ventricular  infarction,  this  dis- 
tinction is  mandatory.  For  this  reason,  the  ECG 
was  also  recorded  with  lead  electrodes  placed 
on  the  right  anterior  hemithorax.  These  addi- 
tional leads  did  not  show  evidence  of  right  ven- 
tricular infarction.  Since  posterior  wall  myocar- 
dial infarction  was  not  a diagnostic  consideration 
in  this  patient,  no  recordings  were  made  from 
the  left  posterior  hemithorax  (ie,  V7-V9). 

The  rapid  recognition  of  acute  myocardial 
infarction  is  imperative.  Therefore,  in  patients 
in  whom  the  clinical  presentation  is  consistent 


544  J La  State  Med  Soc  VOL  152  November  2000 


with  this  diagnosis,  pay  close  attention  to  the 
ST  segments.  Deviations  of  the  ST  segment 
(elevation  or  depression)  are  helpful  in  the  initial 
triage  of  patients  with  acute  coronary  syndromes 
and  in  selecting  candidates  for  revascularization. 

Patients  who  exhibit  ST-segment  elevation 
are  assigned  to  reperfusion  therapy  (fibrinolytic 
agents  or  percutaneous  transluminal  coronary 
angioplasty),  unless  contraindications  exist. 
Such  therapy  is  most  effective  if  instituted  in  the 
first  6 hours  of  the  infarction  process. 
Classification  of  acute  myocardial  infarction  into 
Q-wave  and  non-Q  wave  infarctions  is  of  no 
value  in  the  early  diagnosis  of  infarction  nor  in 
selecting  initial  treatment  for  these  patients.  Such 
an  ECG  distinction  takes  time,  1 to  2 days. 

Elevation  of  the  ST  segments  is  not  a specific 
finding  for  acute  myocardial  infarction. 
Therefore,  a carefully  taken  history,  a focused 
physical  examination,  and  the  use  of  serum 
cardiac  markers  remain  as  very  important  items 
in  the  overall  evaluation  of  the  patient  with  such 
findings.  Other  cardiac  and  non-cardiac 
disorders  may  display  ST-segment  elevation  in 
the  absence  of  coronary  artery  disease.  Among 
the  cardiac  disorders  is  acute  fulminant 
myocarditis.  Pseudo-infarction  ST-segment 
elevation  has  also  been  reported  in  non-cardiac 
disorders,  such  as  esophageal  rupture  and 
esophageal  food  impaction,  hypocalcemia  due 
to  hypoparathyroidism,  and  acute  pancreatitis, 
to  name  a few. 


Dr  Martinez-Lopez  is  a specialist  in  cardiovascular 
diseases  affiliated  with  the  Cardiology  Service,  Department 
of  Medicine,  Texas  Tech  University  Health  Sciences  Center 
and  Thomason  General  Hospital  in  El  Paso,  Texas. 


Otol  gy / 




Congenital  Nasal  Pyriform 
Aperture  Stenosis 

James  P.  Lacey,  MD,  MPH  and  Karla  Brown,  MD 


Congenital  nasal  pyriform  aperture  stenosis  is  a rare  cause  of  pediatric  nasal  airway  obstruc- 
tion. As  infants  are  obligate  nasal  breathers,  nasal  obstruction  and  even  severe  nasal  conges- 
tion can  lead  to  apnea  and  respiratory  distress.  Congenital  nasal  pyriform  aperture  stenosis 
was  first  described  by  Brown  et  al  in  1989.  The  narrowing  of  the  nasal  pyriform  aperture  is 
thought  to  be  due  to  bony  overgrowth  of  the  nasal  process  of  the  maxilla  during  fetal  devel- 
opment. Because  of  the  association  this  anomaly  has  with  other  midline  defects,  such  as 
holoprosencephaly,  it  is  important  to  recognize  it  and  pursue  a thorough  workup.  We  present 
a case  of  a patient  with  pyriform  aperture  stenosis  and  solitary  central  megaincisor.  This 


patient  initially  presented  to  our  clinic  with  a 
ing,  and  failure  to  thrive. 

Nasal  airway  obstruction  in  the  newborn 
can  be  a medical  emergency.  There  are 
many  causes  of  nasal  airway  obstruc- 
tion in  the  newborn.  Congenital  nasal  pyriform 
aperture  stenosis  (CNPAS)  is  a rare  cause  of  pe- 
diatric nasal  airway  obstruction.  CNPAS  was 
first  described  by  Brown  et  al1  in  1989.  It  has  been 
proposed  that  the  nasal  pyriform  aperture  is  nar- 
rowed due  to  bony  overgrowth  of  the  nasal  pro- 
cess of  the  maxilla.  The  development  of  an  up- 
per respiratory  tract  infection  can  lead  to  com- 
plete nasal  obstruction.  As  newborn  infants  are 
obligate  nasal  breathers,  nasal  obstruction  sec- 


history  of  nasal  airway  obstruction,  poor  feed- 

ondary  to  stenosis  or  even  partial  obstruction 
associated  with  nasal  congestion  can  lead  to 
apnea.  After  a diagnosis  of  CNPAS  is  made,  the 
maintenance  of  an  adequate  airway  is  of  the  ut- 
most importance.  On  most  cases,  conservative 
measures  of  support  are  adequate.  However,  if 
conservative  therapy  does  not  alleviate  the 
child's  symptoms  then  surgical  options  should 
be  discussed  with  the  parents. 

ETIOLOGY 

Although  the  developmental  etiology  of  pyri- 
form aperture  stenosis  is  unclear,  nasal  devel- 


546  J La  State  Med  Soc  VOL  152  November  2000 


opment  of  the  embryo  is  known.  Development 
begins  as  paired  olfactory  placodes  form  dur- 
ing the  third  week  after  conception.  These 
placodes  will  form  nasal  pits,  which  will  deepen 
into  the  surrounding  frontonasal  process.  The 
frontonasal  process  is  divided  into  medial  and 
lateral  processes  by  these  pits.  The  lateral  pro- 
cesses will  ultimately  fuse  with  the  developing 
maxillae  to  form  the  pyriform  aperture  and  lat- 
eral nasal  wall.  Maxillary  ossification  begins 
from  the  growth  center  above  the  canine  tooth 
germ.  The  maxillary  ossification  meets  the  car- 
tilaginous nasal  capsule  and  forms  the  lateral 
nasal  wall  around  the  fourth  month  of  develop- 
ment. It  is  postulated  that  an  overgrowth  of  this 
ossification  at  the  area  of  the  nasal  process  of 
the  maxilla  is  responsible  for  the  stenosis.1 

Congenital  pyriform  aperture  stensosis  can 
be  an  isolated  entity  or  it  may  be  associated  with 
other  midline  defects.  CNPAS  is  a midline  de- 
velopmental abnormality  and  has  been  associ- 
ated with  the  holoprosencephaly  spectrum. 
Holoprosencephaly  is  a form  of  midline  dysgen- 
esis affecting  the  prosencephalon  and  midline 
facial  structures.  The  CNS  and  craniofacial  struc- 
tures are  affected  in  various  combinations  and 
to  varying  degrees.  CNS  manifestations  can 
range  from  normal  intelligence  and  structure  to 
alobar  holoprosencephaly.  Craniofacial  abnor- 
malities may  also  vary  in  severity.  The  more  se- 
vere cases  present  with  cyclopia  and  agenesis 
of  the  premaxilla  with  cleft  palate.  The  combi- 
nation of  CNPAS  and  a central  megaincisor  is  a 
manifestation  on  the  milder  end  of  the  spectrum. 
However,  the  presence  of  a central  megaincisor 
associated  with  pyriform  aperture  stenosis  in- 
creases the  likelihood  of  additional  anomalies 
on  the  holoprosencephaly  spectrum  being 
present.  This  should  prompt  further  evaluation. 
Pituitary  deficiency,  ocular  coloboma,  and  chro- 
mosome deficiencies  are  other  defects  that  have 
been  associated  with  this  syndrome.  The  chro- 
mosome abnormality  most  commonly  associ- 
ated is  del(18p),  r(18),  or  del(13q).  Teratogens 
also  have  been  shown  to  be  responsible  for  some 
forms  of  holoprosencephaly.  In  addition,  Barr  et 
al  reported  a 200-fold  increase  in  the  incidence 


of  holoprosencephaly  with  maternal  diabetes.2 

CLINICAL  SIGNS/SYMPTOMS 

Patients  affected  with  CNPAS  present  with 
symptoms  of  nasal  airway  obstruction.  Because 
these  infants  are  obligate  nasal  breathers,  ob- 
struction can  cause  severe  respiratory  distress. 
The  baby  will  generally  not  present  with  frank 
stridor  but  with  a snorting  respiratory  effort  and 
nasal  flaring.  Cyanosis  episodes  are  frequent  and 
are  often  interrupted  by  periods  of  crying,  which 
will  improve  the  baby's  color.  This  combination 
of  cyanosis  resolved  by  crying  is  known  as  cy- 
clical cyanosis.  Cyclical  cyanosis  is  a feature  of 
bilateral  posterior  choanal  atresia  as  well  as 
CNPAS.  It  can  be  seen  in  any  infant  with  an  ob- 
structed nasal  airway.  In  severe  cases,  chest  re- 
tractions and  paradoxical  breathing  patterns 
may  be  noted. 

The  nasal  obstruction  affecting  a child  with 
CNPAS  may  also  interfere  with  his  feeding.  The 
more  superior  cervical  position  of  the  neonatal 
larynx  allows  for  a nasopharyngeal  airway  dur- 
ing sucking.  This  superior  position  allows  for 
overlap  of  the  epiglottis  and  the  velum.  This 
overlap  directs  milk  or  formula  around  the  dor- 
sum of  the  tongue  and  laterally  around  the  epi- 
glottis, protecting  the  airway.  Nasal  obstruction 
interferes  with  this  normal  feeding  pattern.  The 
infant  may  become  very  frustrated  and  irritable 
during  feedings.  Frequent  interruptions  of  feed- 
ing in  order  for  the  infant  to  cry  and  "catch"  its 
breath  are  common.  Feeding  time  increases  and 
may  become  very  laborious  for  the  mother.  The 
infant  may  also  become  cyanotic  or  exhibit  cir- 
cumoral  pallor  during  feeds.  For  all  these  rea- 
sons, the  affected  child  may  have  difficulty  with 
weight  gain  and  even  failure  to  thrive.  Even  the 
calories  that  are  taken  in  are  consumed  more 
rapidly  due  to  the  increase  in  work  of  breathing 
and  resultant  calorie  expenditure. 

A thorough  physical  examination  will  often 
reveal  the  cause  of  the  nasal  obstruction.  The  dif- 
ferential diagnosis  must  include  midline  nasal 
masses  such  as  encephaloceles,  gliomas,  or 
dermoids.  Craniofacial  anomalies  including 


J La  State  Med  Soc  VOL  152  November  2000  547 


Treacher  Collins  and  Apert  syndromes  can  also 
present  with  nasal  airway  obstruction.  Adenoid 
hypertrophy  is  the  most  common  form  of  pedi- 
atric nasal  obstruction  and  can  be  seen  even  in 
very  young  infants. 

On  initial  clinical  examination  the  narrow- 
ing of  the  pyriform  aperture  may  be  overlooked. 
The  usual  clinical  finding  is  failure  to  pass  a no. 
5 or  6 French  feeding  catheter  beyond  the  nar- 
rowed area  in  the  anterior  nasal  cavity. 
Nasopharyngoscopy  may  be  difficult  or  impos- 
sible for  the  same  reason.  This  examination 
should  only  be  attempted  with  an  infant  size  (< 
2.7  mm)  fiberoptic  flexible  scope.  Care  should 
be  taken  to  avoid  "forcing"  the  examination  and 
traumatizing  the  mucosa  which  can  result  in 
increased  edema  and  worsening  obstruction. 
Computed  tomography  is  the  imaging  study  of 
choice  to  confirm  the  diagnosis.  Many  of  these 
children  will  have  been  presumed  to  have  pos- 
terior choanal  atresia  prior  to  radiographic  stud- 
ies. CT  is  a good  study  to  reveal  the  bony  over- 
growth of  the  maxillary  nasal  process  but  also 
provides  valuable  information  about  nasal  and 
skull  base  anatomy.  An  axial  CT  scan  will  reveal 
bony  stenosis  at  the  pyriform  aperture  with  flar- 
ing of  the  bone  edges.  It  is  also  helpful  in  elimi- 
nating other  anomalies  such  as  choanal  atresia 
or  midline  nasal  masses.  The  CT  may  reveal  a 
single  central  maxillary  incisor  and  crowding  of 
the  anterior  teeth  or  other  midfacial  defects.  This 
finding  is  not  always  present,  but  when  it  is  the 
risk  of  associated  anomalies  increases.  A mag- 
netic resonance  imaging  scan  can  also  be  help- 
ful to  evaluate  the  infant  for  subtle  midline  brain 
dysgenesis  and  pituitary  gland  abnormalities. 

MANAGEMENT 

The  initial  treatment  of  these  children  involves 
relieving  respiratory  distress  and  establishing  an 
adequate  airway.  Supplemental  oxygen  may 
provide  immediate  relief.  However,  it  may  re- 
quire intubation  in  order  to  stabilize  the  infant 
until  definitive  management.  Mild  stenosis  can 
often  be  managed  conservatively  with  nasal 
humidification  and  topical  nasal  decongestants. 


Liu  et  al  proposed  that  the  ability  to  pass  a 5 Fr 
feeding  catheter  through  the  pyriform  aperture 
forecasts  success  at  conservative  management.3 
If  the  infant  responds  well  to  this  management 
and  can  be  treated  as  an  outpatient  he  should 
go  home  on  an  apnea  monitor.  Parents  are  in- 
structed in  proper  care  and  encouraged  to  mini- 
mize nasal  suctioning  which  can  exacerbate  the 
problem.  Parents  should  also  be  given  instruc- 
tion in  CPR  prior  to  discharge.  A McGovern 
nipple  can  be  helpful  in  maintaining  an  adequate 
airway  and  overcoming  feeding  difficulties.  This 
is  often  a temporizing  maneuver  used  to  man- 
age patients  with  bilateral  choanal  atresia.  Par- 
ents must  be  cautioned  to  have  their  child  evalu- 
ated during  an  upper  respiratory  tract  infection 
as  this  may  lead  to  acute  respiratory  distress. 
Again,  some  infants  may  require  intubation  for 
airway  management  until  definitive  treatment. 

The  infant  with  CNPAS  should  also  undergo 
a complete  genetic  workup.  This  should  include 
an  evaluation  by  the  geneticist  for  karyotype 
analysis  as  well  as  parental  counseling  and  fam- 
ily history.  An  endocrine  evaluation  to  rule  out 
any  hypothalamic-pituitary-thyroid-adrenal  axis 
deficiency  may  also  be  necessary. 

More  severe  cases,  or  those  that  fail  conser- 
vative therapy,  will  require  surgical  repair.  Two 
approaches  have  been  described  to  repair  pyri- 
form aperture  stenosis:  transnasal  and  sublabial. 
The  transnasal  approach  is  associated  with  a 
higher  recurrence  rate  and  is  a technically  diffi- 
cult procedure  to  perform  on  a neonate.  The 
sublabial  approach  is  our  preference  and  has 
been  described  elsewhere.  Briefly,  the  approach 
used  is  to  resect  bone  from  the  inferior  margin 
of  the  anterior  nasal  aperture.  It  is  performed 
using  an  operating  microscope  and  ear  instru- 
ments to  allow  excellent  visualization  and  pres- 
ervation of  the  nasal  mucosa.  The  nasal  mucosa 
is  elevated  off  the  floor  of  the  nose  and  walls  of 
the  nasal  cavity  to  expose  the  bony  stenosis. 
Caution  should  be  used  along  the  floor  of  the 
nose  to  avoid  damage  to  the  tooth  buds.  The 
bony  nasal  aperture  should  be  widened  suffi- 
ciently with  a cutting  burr  to  allow  a 3.5  mm 
endotracheal  tube  to  be  placed  in  the  nasal  cav- 


548  J La  State  Med  Soc  VOL  152  November  2000 


ity  as  a stent.  The  stents  are  placed  bilaterally 
and  should  be  kept  in  place  for  2 to  4 weeks.1 
Krol  et  al  have  described  the  use  of  a bone  curette 
under  direct  visualization  to  enlarge  the  aper- 
ture. They  prefer  to  leave  the  stents  in  place  for 
1 week  to  minimize  patient  discomfort  and  to 
decrease  the  risk  of  bilateral  stent  occlusion  by 
secretions.4  Patients  sent  home  with  stents  in 
place  are  provided  with  home  suction  devices 
and  frequent  saline  irrigation  with  suctioning  of 
the  stents  to  prevent  occlusion. 

If  the  patient  is  not  expected  to  survive  due  to 
other  associated  severe  anomalies,  conservative 
management  alone  should  be  strongly  consid- 
ered. This  would  include  placement  of  an  oropha- 
ryngeal airway,  nasal  suctioning,  and  nose  drops 
as  required  for  comfortable  respiration. 

CASE  STUDY 

C.S.  was  a 30-week-old  gestational  age  male  in- 
fant, the  first  of  twins.  His  twin  brother  did  not 
show  any  signs  of  CNPAS.  He  remained  in  the 
neonatal  intensive  care  unit  at  an  outside  insti- 
tution for  two  and  a half  months.  He  was  noted 
to  have  an  H-type  tracheoesophageal  fistula 
which  was  repaired  during  that  hospital  stay.  He 
was  discharged  to  home  but  continued  to  have 
persistent  respiratory  distress  and  feeding  diffi- 
culties. His  pulmonologist  noted  signs  of  signifi- 
cant upper  airway  obstruction  and  arranged 
evaluation  by  our  service.  Initial  evaluation  re- 
vealed an  irritable  infant  with  noisy  respirations. 
He  had  moderate  retractions  and  appeared  very 
dusky.  His  color  improved  dramatically  with 
crying.  Fiberoptic  examination  revealed  that  the 
child  had  choanal  stenosis  on  the  left  side  as  well 
as  bilateral  pyriform  aperture  stenosis.  The  child 
was  admitted  to  the  pediatric  intensive  care  unit 
and  was  noted  to  have  oxygen  saturations  in  the 
mid-80s  when  he  was  not  crying.  Several  hours 
later  he  had  respiratory  decompensation  that 
required  intubation.  He  underwent  a formal  di- 
rect laryngoscopy  and  bronchoscopy  under  an- 
esthesia and  was  noted  to  have  a subglottic 
stenosis  that  compromised  the  airway  by  about 
50%.  This  was  presumed  to  be  secondary  to  his 


previous  intubation.  Because  of  multiple  levels 
of  airway  obstruction  and  the  infant's  small  size 
with  failure  to  thrive,  a tracheostomy  was  per- 
formed to  bypass  the  obstruction  and  provide 
an  adequate  airway.  A CT  scan  revealed  bony 
narrowing  of  the  pyriform  aperture  of  the  nasal 
cavity  bilaterally  secondary  to  thickening  of  the 
nasal  process  of  the  maxilla  and  flaring  of  the 
bone  edges  (Figure  1).  In  addition,  soft  tissue  was 
noted  to  occlude  the  anterior  aspect  of  the  nasal 
passageway  on  the  right  and  partial  soft  tissue 
narrowing  of  the  anterior  passageway  on  the  left 
at  the  level  of  the  pyriform  aperture.  There  was 
also  a central  megaincisor  noted  and  crowding 
of  the  anterior  teeth  on  CT  scan  (Figures  2 and 
3).  An  MRI  scan  was  performed  to  evaluate  the 
child  for  subtle  midline  brain  dysgenesis  and 
was  normal. 


Figure  1.  Axial  CT  scan  demonstrating  thickening  of 
the  nasal  process  of  the  maxilla  and  flaring  of  the  bone 
edges. 


Evaluation  of  this  child  during  his  hospitaliza- 
tion included  an  endocrine  and  genetic  workup. 
Endocrine  evaluation  revealed  normal  thyroid 
stimulating  hormone,  T4,  and  cortisol  levels.  The 
ACTH  stimulation  test  was  also  normal.  Genetic 
evaluation  revealed  normal  XY  genotype.  A 


J La  State  Med  Soc  VOL  152  November  2000  549 


CT  Hi  Speed  Adv  SV'3#TMCT  TULANE  UNIV  MEDICAL  CENTER 

Ex:  18180 

Se:2  3M  M 689715 

IOM  325.6  FEB  5.  2000 

Im:6  c.l- 

050V  14 . Ocm 
STNC'/I 


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R 1 1 L 

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mA  170 

Adult  Head 
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Figure  2.  Axial  CT  scan  demonstrating  central 
megaincisor. 

FISH  study  for  DiGeorge  syndrome  was  normal 
as  well.  The  child's  pediatrician  was  also  con- 
tacted concerning  the  twin  brother  who  was 
found  to  have  no  similar  anomalies. 

Before  plans  for  further  surgical  intervention 
can  be  made,  this  child  will  undergo  a repeat 
laryngoscopy  and  bronchoscopy  and  examina- 
tion of  his  nose  and  nasopharynx.  The  results  of 
the  examination  have  improved  somewhat  with 
growth  and  the  patient's  need  for  surgical  re- 
pair of  the  pyriform  aperture  stenosis  and  sub- 
glottic stenosis  will  need  to  be  reassessed.  The 
repair  of  the  choanal  atresia  and  pyriform  aper- 
ture stenosis  will  likely  be  performed  first  and 
the  subglottic  stenosis  repair  staged  at  a later 
date  if  necessary  for  decannulation. 

CONCLUSION 

Although  it  is  an  unusual  problem,  it  is  impor- 
tant to  consider  CNPAS  in  the  differential  diag- 
nosis of  nasal  airway  obstruction  in  the  neona- 
tal population.  Although  symptoms  are  most 
often  mild  and  patients  can  be  managed  conser- 
vatively, infants  may  present  with  severe  respi- 
ratory distress.  The  presentation  of  cyclical  cy- 
anosis relieved  by  crying,  similar  to  the  findings 
of  bilateral  choanal  atresia,  should  prompt  fur- 
ther investigation.  Computed  tomography  can 


CT  Hi  Speed  Adv  3Y3#TMCT  TULANE  UNIV  MEDICAL  CENTER 

Ex: 18180 

Se:2  3M  M 689715 

OH  329.6  FEB  5.  2000 

Im:10  c j- 

OFOV  14 . Ocm 
STND/I 


Adult  Heed 
1 /Omni/ 1 : 1 
Tilt  -3.0 

1.0  s/HE  10:27:45  AM/09.00 


Figure  3.  Axial  CT  scan  demonstrating  crowding  of 
anterior  teeth. 

be  used  to  confirm  the  diagnosis.  Early  referral 
for  evaluation  and  treatment  is  a necessity  and 
can  prevent  more  serious  complications  such  as 
failure  to  thrive  and  respiratory  compromise. 
With  proper  conservative  management,  many 
patients  can  be  spared  surgical  intervention. 

REFERENCES 

1 . Brown  OE,  Myer  CM,  Manning  SC.  Congenital  nasal 
pyriform  aperture  stenosis.  Lcuyngoscope  1989;99:86- 
91. 

2.  Barr  MH.  Holoprosencephaly  in  infants  of  diabetic 
mothers.  J Pediatr  1983;102:565-568. 

3.  Krol  BJ,  Hulka  GF,  Drake  A.  Congenital  nasal  pyriform 
aperture  stenosis  in  the  monozygotic  twin  of  a child  with 
holoprosencephaly.  Otolaryngol  Head  Neck  Surg 
1998;118:679-681. 

4.  Hui  Y,  Friedberg  J,  Crysdale  WS.  Congenital  nasal 
pyriform  aperture  stenosis  as  a presenting  feature  of 
holoprosencephaly.  Int  J Pediatr  Otorhinolaryngol 
1995;31:263-274. 

Dr  Lacey  is  a resident : 
Department  of  Otolaryngology -Head  and  Neck  Surgery 
Tulane  University  School  of  Medicine 
in  New  Orleans ;,  Louisiana. 

Dr  Brown  is  Assistant  Professor, 
Department  of  Otolaryngology -Head  and  Neck  Surgery, 
Tulane  University  School  of  Medicine 
in  New  Orleans,  Louisiana. 


550  J La  State  Med  Soc  VOL  152  November  2000 





Congenital  Limb  and  Bleeding  Disorder 

Colleen  M.  Costelloe,  MD;  Edward  H.  De  Mouy,  MD; 
and  Harold  R.  Neitzschman,  MD 


A 1-month-old  African-American  infant  boy  was  transferred  to  our  institution  for  central  venous 
line  placement  due  to  a need  for  frequent  platelet  transfusions.  An  orthopedic  consult  was 
also  requested. 


Figure  2.  AP  of  left  upper  extremity. 


What  is  your  diagnosis? 
Elucidation  is  on  page  552. 


J La  State  Med  Soc  VOL  152  November  2000  551 


Radiology  Case  of  the  Month 
Case  Presentation  is  on  page  551. 

RADIOLOGIC  DIAGNOSIS  - Thrombocytopenia 
absent  radius  syndrome  (TAR) 

INTERPRETATION  OF  IMAGING 

The  radius  is  completely  absent  bilaterally.  Ra- 
dial deviation  of  the  hand  is  seen.  The  ulna  and 
humerus  are  normal  in  shape  and  length  in  this 
relatively  mild  case. 

DISCUSSION 

TAR  syndrome  is  a congenital  disorder  involv- 
ing absent  radius  (thumb  must  always  be 
present)  and  thrombocytopenia.  It  is  believed  to 
follow  autosomal  recessive  inheritance.  Differ- 
ential diagnosis  includes  Fanconi's  anemia, 
Robert's  syndrome.  Holt  Orham  syndrome,  and 
SC  phocomelia.1  Thrombocytopenia  is  symp- 
tomatic in  90%  of  children  born  with  this  disor- 
der. Thrombocytopenia  is  most  severe  in  early 
childhood,  often  in  the  first  2 years,  after  which 
it  spontaneously  improves,  approaching  normal 
by  adulthood.2 

In  addition  to  thrombocytopenia,  complete 
absence  of  the  radius,  and  presence  of  the  thumb, 
other  common  upper  extremity  bony  abnormali- 
ties in  TAR  include  a malformed,  shortened  ulna 
or  humerus.  Lower  extremity  abnormalities, 
potentially  involving  the  hips,  knees,  or  feet, 
occur  in  approximately  50%  of  patients.2  Cardiac 
abnormalities  are  seen  in  approximately  30%  of 
patients  and  may  include  atrial  septal  defect  or 
tetralogy  of  Fallot.2 

Diagnosis  of  TAR  can  be  made  prenatally 
with  a combination  of  diagnostic  ultrasound  to 
reveal  the  absent  radius  and  ultrasound  guided 
cordocentesis  to  confirm  thrombocytopenia.1 
Cesarean  section  is  preferred  over  vaginal  de- 
livery in  order  to  reduce  bleeding  complications. 
Platelet  transfer  has  been  successfully  performed 
in  utero,  utilizing  ultrasound  guidance  to  deliver 
platelets  to  the  umbilical  vein.3  Bone  marrow 
transplant  has  been  performed  on  a 2-year-old 


child  with  persistent,  symptomatic  thrombocy- 
topenia. Six-year  follow-up  revealed  normal 
platelet  counts  and  a stable  graft.4  Radial  devia- 
tion of  the  hand  is  seen  due  to  insertion  of  fore- 
arm musculature  onto  the  carpals  rather  than 
the  absent  radius.  This  is  corrected  by  central- 
ization of  the  wrist  on  the  hand  with  reattach- 
ment of  muscles  or  use  of  tendon  interposition. 
Braces  or  surgery,  such  as  derotational  osteoto- 
mies and  tendon  contracture  release,  are 
neccessary  to  correct  lower  extremity  abnormali- 
ties. Surgery  is  often  postponed  until  the  child 
is  several  years  old,  when  the  thrombocytope- 
nia has  largely  resolved.5 

REFERENCES 

1.  Labrune  PH,  Pons  JC,  Khalil  M,  et  al.  Antinatal 
thrombocytopenia  in  three  patients  with  TAR 
(thrombocytopenia  with  absent  radius)  syndrome. 
PrenatDiagn  1993;13:463-466. 

2.  Hall  JG.  Thrombocytopenia  and  absent  radius 
(TAR)  syndrom e.JMed  Genet  1987;24:79-83. 

3.  Weinblatt  M,  Petrikovsky  B,  Bialer  M,  et  al.  Prenatal 
evaluation  and  in  utero  platelet  transfusion  for 
thrombocytopenia  absent  radius  syndrome.  Prenat 
Diagn  1994;14:892-896. 

4.  Brochstein  JA,  Shank  B,  Kernan  NA,  et  al.  Marrow 
transplantation  for  thrombocytopenia-absent 
radius  syndrome.  / Pediatr  1992;121:587-589. 

5.  Fromm  B,  Niethard  FU,  Marquardt  E. 
Thrombocytopenia  and  absent  radius  (TAR) 
syndrome.  Int  Orthop  1991;15:95-99. 


Dr  Costelloe  is  in  her  fourth  year  of  radiology  residency 
at  Tulane  University  Health  Sciences  Center 
in  New  Orleans , Louisiana. 

Dr  De  Mouyis  Professor  and  Chairman  of  Radiology 
at  Tulane  University  Health  Sciences  Center 
in  New  Orleans , Louisiana. 

Dr  Neitzschman  is  Professor  of  Radiology  and  Pedia  tries 
at  Tulane  University  Health  Sciences  Center 
in  New  Orleans , Louisiana. 


552  J La  State  Med  Soc  VOL  152  November  2000 


History  of  Medicine 


Preparation  for  and  Description  of 
the  Cesarean  Section 


Gustavo  Colon,  MD 


I'm  quite  often  fascinated  as  I review  back 
issues  of  the  Journal  on  the  extent  of  the  de 
scriptions  of  operative  procedures  as  well 
as  some  of  the  photographic  graphics  that  be- 
gan to  appear  in  the  late  19th  Century.  The  fol- 
lowing is  an  article  that  was  written  by  Dr 
Gustav  Zinke  from  Cincinnati,  Ohio,  presented 
at  the  Ohio  Medical  Association,  and  subse- 
quently printed  in  the  August  1892  Journal.  The 
first  part  of  the  article  deals  with  the  criteria  and 
indications  for  a Cesarean  operation  as  practiced 
in  the  late  19th  Century  What  is  interesting  is 
the  description  of  the  operation  including  the 
photographic  plates.  What  is  observed  are  three 
physicians  operating  on  a mannequin  which  had 
been  manufactured  by  the  P.  Goldsmith  and 
Company  of  Covington,  Kentucky.  This  manne- 
quin apparently  was  available  to  all  medical 
schools  and  physicians  for  training  in  this  par- 
ticular operative  procedure.  What  follows  is  the 
detailed  operative  management  of  a Cesarean 
section,  which  I found  to  be  an  extremely  de- 


tailed discussion  of  the  procedure  including  the 
manner  of  doing  it  out  of  a hospital  setting. 

"This  includes:  (a)  Preparation  of  patient,  her 
bed  and  room  in  which  the  operation  is  to  be 
performed,  (b)  What  anesthetic  shall  be  em- 
ployed? (c)  What  instruments  and  other  articles 
are  necessary  for  the  operation?  (d)  Best  time  for 
the  operation,  (e)  The  operation  itself;  and  (f)  The 
after  treatment. 

"(a)  Much  will  depend  upon  when,  where 
and  how  we  find  the  patient.  Whether  she  be  in 
the  country,  town  or  city;  whether  she  is  already 
in  labor,  and  her  condition  such  as  to  demand 
prompt  interference,  with  little  or  no  time  left 
for  preparation.  But  it  should  always  be  remem- 
bered that  an  aseptic  condition  of  the  mother,  as 
well  as  of  the  operator,  his  assistants  and  instru- 
ments, are  most  essential  to  success.  Whatever 
little  time  the  operator  may  have  at  his  disposal 
should  be  employed  in  washing  thoroughly, 
with  soap  and  water,  those  parts  of  the  mother 's 
body  which  are  concerned  in  the  operation.  The 


J La  State  Med  Soc  VOL  1 52  November  2000  553 


instruments,  too,  as  well  as  the  hands  of  the  op- 
erator and  his  assistants,  should  receive  thor- 
ough aseptic  treatment.  Antiseptics  play  an  all- 
important  part  under  such  circumstances.  The 
rest,  such  as  cleansing  the  patient's  body,  chang- 
ing her  clothes  on  the  bed  and  cleaning  the  room, 
all  may,  in  an  emergency,  be  postponed  until  af- 
ter the  operation. 

"If  the  case  comes  under  observation  at  a pe- 
riod of  gestation  which  gives  time  for  prepara- 
tion — say  a few  days,  weeks  or  a month  or  more, 
nothing  should  be  left  undone  that  may  render 
the  patient  and  her  surroundings  most  favorable 
under  the  circumstances.  If  she  can  be  removed 
to  a special  hospital,  one  devoted  to  abdominal 
surgery,  it  should  be  done.  A general,  especially 
a public,  hospital  should  be  avoided;  unless  it 
be  provided  with  a building  and  an  operating 
room  appointed  and  set  apart  especially  for  work 
of  this  kind.  There  can  be  no  doubt  the  chances 
for  recovery  are  much  better  in  special  hospi- 
tals. The  patient's  home,  though  the  humblest 
in  the  world,  is  preferable  for  the  performance 
of  the  operation  to  a hospital  filled  with  patients 
of  every  description  and  having  but  one  operat- 
ing room. 

"The  question  of  premature  delivery  is 
hardly  to  be  considered  here,  since  it  is  self-evi- 
dent that,  if  the  patient  can  be  safely  delivered 
of  a seven  or  eight  months  child,  this  procedure 
should  be  adopted  in  preference  to  Cesarean 
section. 

"As  soon  as  the  performance  of  hysterotomy 
has  been  determined  upon,  whether  in  a hospi- 
tal or  at  the  home  of  the  patient,  every  precau- 
tion should  be  used  for  the  purpose  of  insuring 
safety.  Thus,  it  will  be  well  if  the  patient  receives 
a daily  vaginal  douche  (1/4000  sol.  of  bichlo- 
ride), a warm  bath,  and  a change  of  underwear, 
for  several  days  prior  to  the  operation.  Saline 
cathartics  are  the  best  for  the  purpose  of  secur- 
ing free  and  daily  evacuation.  Rectal  injections 
of  tepid  water  will  assist  in  relieving  the  bowels 
of  their  contents.  On  the  evening  before,  the  ab- 
domen, mons  veneris  and  labia  should  be 
shaved,  and  an  abdominal  binder  with  perineal 
pad,  antiseptically  prepared,  should  be  applied. 


The  bed  which  she  is  to  occupy  after  the  opera- 
tion should  also  be  absolutely  clean;  the  bedstead 
taken  apart  and  thoroughly  scrubbed;  the  mat- 
tress and  bed  clothes  fumigated,  then  well  aired; 
sheets  and  pillow-slips  rendered  aseptic  and 
antiseptic  by  boiling  and  subsequent  dipping 
into  a 1/2000  bichloride  solution  before  drying. 
If  she  is  in  her  own  home,  the  same  apartment 
may  be  used  for  bed  and  operating  room.  This 
room  is  to  be  prepared  as  follows:  If  walls  and 
ceilings  are  painted,  they  should  be  washed;  if 
papered,  wiped;  if  neither,  white-washed  and 
whitened.  Windows  and  frames  should  also  be 
washed  and  floor  thoroughly  scrubbed,  and  sub- 
sequently kept  sprinkled  with  a 1 / 2000  bichlo- 
ride solution. 

"The  temperature  of  the  room  should  be  kept 
between  60  and  65  degrees  Fahrenheit  for  at  least 
twenty-four  hours  prior  to  and  between  70  and 
75  degrees  during  the  operation.  A temperature 
of  between  80  and  85  degrees  is  preferable,  for 
the  reason  that  the  patient  maintains  her  own 
temperature  better,  and,  consequently,  the 
breathing  continues  more  regular,  and  the  heart's 
action  is  less  apt  to  fail. 

"The  operator,  his  assistants  and  the  nurse, 
should  be  strictly  aseptic.  This  means  a bath  and 
clean  clothes  in  the  truest  sense  of  the  word.  No 
other  patients  ought  to  be  attended  by  them  pre- 
vious to  the  operation.  Instruments,  sponges, 
dressings  and  towels  must  be  rendered  aseptic 
and  again  sterilized  before  using.  Operating 
gowns  or  jackets,  and  aprons  to  be  worn  by  the 
operator,  assistants  and  nurse,  should  also  be 
sterilized.  An  ordinary  kitchen  table,  properly 
cleaned  and  supplied  with  an  aseptic  blanket  or 
comfort,  pillow,  rubber  and  linen  sheet,  is  am- 
ply sufficient  for  the  purpose  of  an  operating 
table.  The  patient  should  be  dressed  as  "for  the 
night",  an  undershirt  and  sleeping  gown  being 
all  she  ought  to  wear. 

"On  the  morning  of  the  operation,  no  food  is 
to  be  permitted  except  perhaps  a small  cup  of 
very  light  coffee  and  a small  piece  of  toast.  Some 
operators  prohibit  even  this.  Before  or  while  the 
anesthetic  is  administered,  from  one-eighth  to 
one-fourth  of  a grain  of  codeine  or  morphine 


554  J La  State  Med  Soc  VOL  152  November  2000 


may  be  given  subcutaneously 

"Placed  upon  the  table,  her  clothes  are  rolled 
up  under  her  shoulders;  the  lower  extremities 
are  wrapped  up  in  warmed,  cleaned  blankets, 
and  after  the  antiseptic  abdominal  dressing, 
worn  by  her  during  the  previous  night,  has  been 
removed,  and  her  bladder  emptied,  towels 
wrung  out  in  a warm  bichloride  solution  are  so 
placed  across  and  along  the  sides  of  her  body  as 
to  cover  her  clothes  above,  and  the  blankets  be- 
low. The  abdomen  remains  exposed  to  the  op- 
erator. Enough  sterilized  water  should  be  on 
hand  for  all  purposes.  The  hands  of  the  opera- 
tor and  assistants  are  best  rendered  aseptic  by 
the  method  suggested  by  Howard  Kelly,  the  first 
professor  of  Gynecology  and  Obstetrics  at  the 
Johns  Hopkins  Hospital. 

"(b)  The  choice  of  the  anesthetic  is  left  to  the 
operator.  After  ten  years  of  experience  in  opera- 
tive work,  both  as  assistant  and  principal,  I have 
come  to  the  conclusion  that  it  is  very  satisfac- 
tory to  begin  anesthesia  with  the  use  of  chloro- 
form, and,  after  the  patient  is  unconscious,  to 
continue  with  the  A.C.E.  mixture > "an  ether-chlo- 
roform mixture",  suggested  by  Reeve,  of  Day- 
ton,  Ohio.  When  this  is  followed  by  a total  absti- 
nence from  food  and  drink  during  the  twenty- 
four  hours  following  the  operation,  there  will  be 
but  little,  often  no,  disturbance  from  vomiting. 

"(c)  Instruments  and  other  articles  necessary 
for  the  operation  may  be  briefly  enumerated  as 
follows:  (a)  An  ordinary  scalpel  and  elbow  scis- 
sors for  the  abdominal  incision,  (b)  A grooved 
director,  (c)  Half  a dozen  hemostatic  forceps  (less 
may  answer  the  purpose),  (d)  Ligatures  of  dif- 
ferent sizes  (silver,  silk,  silkworm-gut,  or  cat-gut), 
(e)  Holder  with  sponges  (antiseptic  gauze  or 
cotton  may  be  used  in  place  of  sponges),  (f)  Rub- 
ber tourniquet  twisted  around  the  uterus  before 
it  is  incised  (not  absolutely  necessary),  (g)  Ab- 
dominal irrigator  (may  not  be  needed),  (h)  Io- 
doform powder,  iodoform  or  antiseptic  gauze 
for  dressing  abdominal  wound,  (i)  Adhesion 
plaster,  (j)  Abdominal  bandage  and  perineal  pad. 
(k)  Hypodermic  syringe  and  whiskey  or  brandy 
for  subcutaneous  injections.  (1)  Hot  water  bags 
or  bottles. 


"The  abdominal  incision  (Figure  1)  is  made 
directly  in  the  median  line,  about  six  inches  in 
length,  commencing  immediately  above  the  um- 
bilicus, and  continued  toward  the  symphysis  pu- 
bis. It  is  not  absolutely  necessary  to  make  the 
cut  directly  through  the  linea  alba.  Pean,  a 19th 
Century  French  Gynecological  surgeon  and  Tait, 
a 19th  Century  English  Gynecological  surgeon, 
prefer  to  penetrate  the  peritoneal  cavity  just  to 
one  or  the  other  side  of  it.  They  claim  it  is  diffi- 
cult to  bring  and  hold  in  apposition  the  two  apo- 
neurotic edges  of  the  cut,  and,  if  this  fails,  her- 
nia easily  results  as  a consequence;  this  can  be 
obviated,  it  is  said,  by  entering  at  one  side  of  the 
linea  alba.  This  argument  suggests  itself  as  plau- 
sible. After  the  peritoneal  cavity  has  been 
reached,  the  incision  is  best  completed  and  elon- 
gated by  the  elbow  scissors. 


Figure  1.  Abdomen  exposed.  Abdominal  incision 
marked. 


J La  State  Med  Soc  VOL  152  November  2000  555 


Figure  2.  Uterus  exposed  and  ready  to  be  incised. 
(Note  inset  drawings  of  the  uterine  sutures.) 


"If  it  is  the  aim  to  eventrate  the 
uterus  before  incising  it,  a six-inch  abdominal 
opening  will  not  suffice.  But  eventration  of  the 
uterus,  prior  to  delivery  of  the  child,  does  not 
commend  itself,  because  it  necessitates  a very 
long  abdominal  incision;  again,  it  is  difficult  to 
turn  out  the  uterus  even  when  the  wound  is  eight 
inches  in  length,  nor  is  there  much  to  be  gained 
by  eventration  of  the  organ  at  this  stage  of  the 
operation.  To  prevent  excessive  hemorrhage,  a 
rubber  tourniquet  may  be  thrown  around  the 
uterus  sufficiently  low  that  no  part  of  the  fetus 
may  come  within  its  grasp.  The  application  of 
the  tourniquet,  however,  requires  the  introduc- 
tion of  at  least  one  hand  into  the  peritoneal  cav- 
ity. It  is  often  difficult  and  frequently  impossible 
to  bring  the  tourniquet  into  position,  and,  after 
this  is  accomplished,  its  purpose  may  be  de- 
feated by  that  part  of  the  fetus  which  presents  at 
the  os,  especially  if  the  membranes  have  rup- 


tured previously.  For  these  reasons,  and  the  loss 
of  valuable  time,  the  tourniquet  is  not  often  em- 
ployed by  experienced  operators.  But  eventra- 
tion of  the  uterus,  as  well  as  the  application  of 
the  tourniquet,  may  be  safely  omitted  during  the 
progress  of  the  operation.  After  all  hemorrhage 
from  the  abdominal  wound  has  been  arrested, 
and  three  or  four  (Figure  2)  sutures  introduced 
in  the  upper  angle  of  the  wound,  the  ends  of 
which  should  be  fixed  by  forceps  and  the  loops 
withdrawn  from  the  wound  and  retracted  up- 
wardly, the  operator  is  ready  for 

THE  UTERINE  INCISION 

"The  uterus,  now  exposed  by  the  abdominal 
wound,  is  to  be  palpated  with  a view  to  deter- 
mine whether  or  not  the  placenta  is  attached  to 
the  anterior  uterine  wall;  if  it  is,  the  wall  will 
feel  thick,  and  the  parts  of  the  fetus  will  not  be 
so  easily  outlined  as  when  the  placenta  is  not 


Figure  3.  Delivery  of  child  and  eventration  of  the 
uterus. 


556  J La  State  Med  Soc  VOL  152  November  2000 


situated  in  this  region. 

"If  only  a section  of  the  margin  of  the  pla- 
centa be  present,  the  incision  should  be  made 
immediately  outside  of  it.  But  when  the  placenta 
has  its  attachment  more  or  less  directly  upon  the 
anterior  wall,  the  incision  should  be  made  as 
nearly  as  possible  in  the  median  line,  and  from 
above  downward.  If  the  placenta  is  not  present, 
this  is  easily  done.  The  womb  may  first  be  punc- 
tured with  a sharp-pointed  scalpel  and  the  open- 
ing quickly  enlarged  with  a blunt-pointed, 
curved  bistoury.  The  hemorrhage  which  follows, 
though  great,  is  not  so  excessive  as  might  be  sup- 
posed; but  when  the  placenta  has  been  so  im- 
planted that  even  its  margin  cannot  be  evaded, 
there  is  nothing  to  be  done  but  to  cut  through 
both  structures  and  deliver  as  quickly  as  pos- 
sible. 

"The  extraction  of  the  child  (Figure  3)  is  best 
accomplished  by  taking  hold  of  one  or  the  other 
extremity  of  the  child.  Some  writers  have  tried 
to  lay  down  the  rule:  "Always  deliver  the  head 
first".  Experience  has  shown  that  this  is  not  al- 
ways practicable.  In  a vertex  presentation,  the 
hand  of  the  operator  would  have  to  pass  down 
over  the  head  to  lift  it  out  of  the  wound.  The 
instant  the  uterus  is  opened  and  the  hand  intro- 
duced, it  contracts,  the  amniotic  fluid  escapes 
and  the  cavity  of  the  uterus,  as  well  as  the 
wound,  rapidly  diminish  in  size;  so  that,  unless 
the  head  is  promptly  and  easily  liberated  before 
this  occurs,  considerable  force  will  be  required 
to  deliver  in  this  manner;  so  much  so,  that  there 
is  great  danger  of  increasing  the  length  of  the 
wound  by  rupture  in  a downward  direction,  an 
accident  which  ought  to  be  avoided  for  self-evi- 
dent reasons.  When  there  is  a large  amount  of 
liquor  amnii  in  a vertex  presentation,  delivery 
of  the  head  in  advance  may,  perhaps,  be  free 
from  difficulty;  without  it,  or  when  the  fluid  has 
already  drained  off,  and  the  uterus  is  firmly  con- 
tracted around  the  child,  no  risk  should  be  in- 
curred or  time  wasted  in  this  direction,  but  de- 
livery effected  by  the  feet.  In  breech  presenta- 
tions, especially  dorso-posterior  positions,  the 
head  readily  finds  its  way  out  of  the  wound;  not 
so,  however,  when  the  back  of  the  child  presents 


anteriorly,  in  which  case,  for  similar  reasons,  it 
may  be  better  to  deliver  by  the  feet. 

"The  only  apprehension  in  a footling  Cesar- 
ean delivery  is  that  the  uterus  may  contract 
around  the  neck  of  the  child  before  the  head  can 
be  removed,  and  thus  the  life  of  the  child  be  sac- 
rificed before  it  is  extracted.  When  this  danger 
is  borne  in  mind,  however,  the  uterine  opening 
may  be  quickly  enlarged  by  scissors  or  knife  kept 
ready  for  the  purpose.  The  same  rules  which 
guide  us  in  the  delivery  of  the  aftercoming  head, 
per  via  naturales,  should  here  be  observed;  the 
object  of  which  is  to  throw  the  smallest  diam- 
eters of  the  head  across  the  passage.  During  de- 
livery of  the  child,  eventration  of  the  uterus  may 
be  effected  and  the  three  sutures,  previously  in- 
troduced into  the  upper  angle  of  the  abdominal 
wound,  closed  by  an  assistant  to  prevent  intes- 
tinal prolapse.  The  child  delivered,  the  cord  is 
tied  in  the  ordinary  way. 


Figure  4.  Sutured  uterus  ready  to  be  returned  to  the 
abdomen. 


J La  State  Med  Soc  VOL  152  November  2000  557 


"The  removal  of  the  placenta  may  be  effected 
by  gentle  traction  upon  the  cord,  or,  if  adherent, 
the  fingers  may  be  introduced  into  the  cavity  and 
the  organ  separated  from  its  attachment.  The 
uterine  cavity  is  then  irrigated  and  dusted  with 
iodoform  powder. 

"Proper  suturing  of  the  uterine  wound  is, 
next  to  strict  asepsis,  the  most  important  feature 
of  success  in  this  operation.  (Figure  4)  It  consists 
of  bringing  the  wound  together  by  both  deep 
and  superficial  sutures.  Silk,  silver-wire  and  cat- 
gut may  be  employed  for  this  purpose.  Cat-gut, 
unless  absolutely  aseptically  and  antiseptically 
prepared,  is  dangerous,  for  reasons  evident  to 
all  experienced  surgeons;  silver- wire,  because  it 
cannot  be  absorbed,  may  become  a source  of  ir- 
ritation and  annoyance;  silk  is,  in  the  opinion  of 
most  operators,  the  most  satisfactory  because  it 
creates  no  irritation  and  its  absorption  is  only  a 
question  of  time.  The  deep  sutures  should  be 
passed,  half  an  inch  apart,  through  the  perito- 
neal coat  and  the  musculature  only.  The  inner 
decidual  surface  must  be  avoided  in  every  in- 
stance. The  superficial  sutures  are  passed  be- 
tween the  deep  sutures  and  grasp  the  peritoneal 
surface  only,  after  the  method  of  Lambert.  The 
object  to  be  attained  is  not  only  to  bring  the 
wound  surfaces  into  close  and  exact  apposition, 
but  to  cause  its  peritoneal  edges  to  dip  down 
into  the  wound,  and  thus  secure  a rapid  union 
and  prevent  oozing  from  the  uterine  cavity.  The 
uterus  is  now  dropped  back  into  the  abdomen, 
which,  if  deemed  necessary,  may  be  irrigated 
with  warm,  boiled  water.  The  abdominal  inci- 
sion is  closed,  and  the  toilet  made  as  in  an  ordi- 
nary ovariotomy.  As  a rule,  no  drainage  tube  is 
needed.  A hypodermic  injection  of  the  fid.  ext. 
of  ergot  is  then  made,  and  the  patient  placed  in 
bed. 

"The  after  treatment  is  very  simple:  No  food 
or  drink  during  the  first  twenty-four  hours.  If 
food  or  stimulants  are  indicated,  they  should  be 
administered  per  rectum;  because,  if  introduced 
into  the  stomach,  vomiting  will  probably  ensue, 
and  this  should  be  avoided,  because  of  its  ten- 
dency to  disturb  a favorable  progress  of  the  case. 
I know  of  no  remedy  or  precaution  which  pre- 


vents or  arrests  the  often  very  disturbing  vomit- 
ing after  an  operation,  other  than  total  abstinence 
from  foot  and  drink  for  a reasonable  time  after 
the  operation.  Opiates  should  never  be  given 
except  for  severe  and  continued  pain.  The  bow- 
els should  be  acted  upon  promptly,  if  they  do 
not  move  spontaneously,  after  fourty-eight 
hours.  Saline  cathartics  are  the  best.  The  vagina 
should  be  antiseptically  irrigated  three  or  four 
times  daily,  during  the  first  few  days,  and  less 
often  thereafter.  If  all  "goes  well",  the  abdomi- 
nal wound  need  not  be  disturbed,  nor  the  su- 
tures removed,  until  the  seventh  day  after  the 
operation." 


Dr  Colon  has  a plastic  surgery  practice 
in  Metairie ; Louisiana.  He  has  lectured  on  the 
history  of  medicine  a t LSU  School  of  Medicine  - 
New  Orleans  and  Tulane  University 
School  of  Medicine  - New  Orleans. 


The  author  and  the  Journal  welcome  comments  on  the 
history  of  medicine. 


558  J La  State  Med  Soc  VOL  1 52  November  2000 


Percutaneous  Recanalization 
of  Thrombosed  Dialysis  Shunts 


Chun  Wang  Tan,  MD;  Royce  Dean  Yount,  MD; 
and  Roberto  E.  Quintal,  MD,  PhD 


Clotted  hemodialysis  shunts  are  a frequent  and  costly  complication  encountered  in  end- 
stage  renal  patients  undergoing  hemodialysis.  Treatment  strategy  is  rapidly  shifting  from 
surgical  thrombectomy  to  percutaneous  recanalization  because  of  the  ready  availability 
of  the  latter  technique  as  well  as  increased  patient  comfort.  We  looked  at  99  episodes  of 
thrombosis  in  hemodialysis  shunts,  33  in  natural  fistulae,  treated  with  several  percutane- 
ous techniques  of  recanalization,  all  with  similar  and  high  success  rates,  regardless  of 
whether  thrombolytics  were  administered  or  not. 


Thrombosis  of  hemodialysis  shunts  is  the 
most  common  reason  for  hospitalization 
in  patients  being  treated  with  long-term 
hemodialysis.1  With  over  120,000  patients  receiv- 
ing hemodialysis  in  the  United  States  each  year, 
the  economic  cost  of  maintaining  a functional 
vascular  access  in  these  patients  is  very  high, 
accounting  for  more  than  $500  million  per  year 
in  health  care  costs.2,3  Thrombosed  shunts  are 
almost  always  associated  with  stenoses  fre- 
quently at  the  venous  outflow  at  the  time  of  the 
thrombotic  episodes.4,5 

The  advent  of  percutaneous  recanalization 
procedures  for  thrombosed  hemodialysis  access 
shunts  has  allowed  preservation  of  these  shunts 
for  longer  use  and  delayed  the  exhaustion  of 


alternative  sites.  The  success  rate  for  percutane- 
ous recanalization  of  thrombosed  hemodialysis 
shunts  has  been  reported  to  be  high6'9  and  the 
complication  rate  low.6'9  However,  most  series 
have  included  only  patients  with  synthetic 
grafts.  We  report  the  results  of  percutaneous  re- 
canalization of  99  thrombosed  hemodialysis 
shunts,  including  33  natural  fistulae,  using  sev- 
eral different  endovascular  methods. 

MATERIALS  AND  METHODS 

Between  May  1992  and  April  1998,  49  patients 
were  referred  for  treatment  of  99  episodes  of 
acute  thrombosis  of  dialysis  shunts.  Thirty-three 
occurred  in  native  fistulae  and  66  in  synthetic 


J La  State  Med  Soc  VOL  152  November  2000  559 


grafts.  We  reviewed  the  medical  records  and 
operative  notes  of  these  patients  to  ascertain  the 
type  of  declotting  procedure  each  received,  the 
success  rate,  and  associated  complications.  The 
immediate  technical  success  was  defined  as  the 
ability  to  use  the  recanalized  hemodialysis  shunt 
for  dialysis  within  24  hours  after  the  procedure. 
The  first  group  of  patients  were  treated  with 
mechanical  disruption  of  the  clot,  thrombolysis, 
and  angioplasty.  The  four  patients  who  had 
contraindications  to  thrombolysis  received  only 
mechanical  disruption  of  clot  with  angioplasty. 
The  procedure  employed  was  as  follows:  The 
shunt  was  cannulated  proximally  and  a wire  was 
advanced  through  the  arterial  anastomosis.  The 
arterial  anastomosis  was  dilated  to  reestablish 
flow  followed  by  mechanical  disruption  ob- 
tained by  rotating  a Judkins  right  coronary  cath- 
eter with  simultaneous  injection  of  small  boluses 
of  urokinase  as  the  catheter  was  withdrawn. 
Subsequently,  the  shunt  was  cannulated  near  the 
arterial  anastomosis,  and  the  catheter  was  ad- 
vanced to  a central  thoracic  vein.  As  the  cath- 
eter was  withdrawn,  small  amounts  of  dye  were 
injected.  Mechanical  disruption  with  thromboly- 
sis was  performed  when  clot  was  encountered. 
Angioplasty  was  performed  throughout  the 
shunt  to  further  disrupt  the  clot.  When  subopti- 
mal  results  were  obtained  after  angioplasty,  a 
Wallstent  (Medinvent-Schneider,  Lausanne, 
Switzerland)  of  appropriate  size  was  deployed. 
As  we  gained  experience,  it  became  obvious  that 
patients  who  received  mechanical  disruption 
and  angioplasty  without  thrombolytics  did  just 
as  well  as  those  with  thrombolytics.  From  then 
on,  our  practice  was  to  perform  mechanical  dis- 
ruption with  angioplasty  first,  administering 
thrombolytics  only  when  significant  residual  clot 
was  identified.  The  latter  group  of  patients  in- 
cluded 17  in  whom  mechanical  disruption  was 
accomplished  using  the  Cragg-McNamara 
thrombolytic  brush  catheter  (Micro  Therapeu- 
tics, San  Clemente,  Calif).10 

RESULTS 

Ninety-nine  episodes  of  dialysis  access  throm- 
bosis developed  in  the  49  patients  studied. 

560  J La  State  Med  Soc  VOL  152  November  2000 


Thirty-three  of  these  episodes  occurred  in  na- 
tive fistulae  and  66  in  synthetic  grafts.  One  pro- 
cedure was  cancelled  after  the  patient  developed 
symptoms  of  congestive  heart  failure  prior  to 
obtaining  graft  access  and  another  patient  with 
severe  chronic  obstructive  lung  disease  devel- 
oped severe  respiratory  distress  before  the  ini- 
tiation of  the  procedure.  These  2 patients  were 
excluded  from  the  study.  Thirty  (97%)  of  31  na- 
tive fistulae  and  62  (94%)  of  the  66  synthetic 
grafts  were  patent  at  the  end  of  the  procedure 
with  an  overall  success  rate  of  95%.  The  success 
rate  of  patients  receiving  thrombolysis  was  91% 
and  without  thrombolysis  was  97%. 

There  were  6 major  complications.  One  pa- 
tient developed  bronchospasm  and  diffuse  ur- 
ticaria at  the  end  of  the  procedure.  He  responded 
well  to  intravenous  steroids,  Hl  and  H0  blockers, 
and  inhaled  bronchodilators.  One  patient  devel- 
oped distal  embolization  to  the  radial  artery 
during  thrombolysis  with  associated  pain  and 
loss  of  radial  pulse.  With  continued  local  uroki- 
nase infusion,  the  patient's  symptom  resolved 
and  the  radial  pulse  returned  to  normal.  She 
subsequently  underwent  surgical  thrombectomy 
of  her  clotted  graft.  In  one  patient  with  a native 
fistula,  an  enlarging  hematoma  developed  at  the 
end  of  the  procedure.  Surgical  exploration  re- 
vealed a perforation  in  the  brachial  artery,  which 
was  successfully  repaired.  One  patient  devel- 
oped stent  migration  proximally  into  his  iliac 
vein  from  the  venous  anastomotic  junction  of  the 
femoral  vein  and  a synthetic  graft.  This  compli- 
cation required  placement  of  a vena  cava  filter 
prophylactically.  Another  patient,  after  success- 
ful recanalization  of  her  synthetic  graft,  devel- 
oped severe  ischemic  neuropathy  of  her  hand 
consistent  with  steal  syndrome.  The  graft  was 
ligated  but  severe  ischemia  persisted.  She  sub- 
sequently developed  gangrenous  changes  in 
some  of  her  digits  requiring  amputation.  In  one 
patient,  recanalized  with  a Cragg-McNamara 
brush,  the  rotating  brush  became  detached  from 
its  drive  shaft.  The  brush  was  successfully  re- 
trieved with  a snare  and  the  recanalization  pro- 
cedure was  successful.  No  patient  developed 
clinical  signs  suggestive  of  pulmonary  embolism 
during  or  after  the  procedure. 


Eighty-six  stenotic  lesions  were  identified  in 
63  patients  in  whom  stenosis  data  were  avail- 
able. The  most  common  site  of  stenosis  was  at 
the  venous  outflow  (42%),  either  at  the  venous 
anastomoti : junction  of  a synthetic  graft  or  junc- 
tion of  a small  with  a larger  vein  (basilic  to  bra- 
chial, cephalic  to  subclavian  vein)  in  native  fis- 
tulae.  The  least  common  site  of  stenosis  was 
within  a synthetic  graft  (1%).  Seven  stents  were 
placed  secondary  to  suboptimal  results,  persis- 
tent narrowing,  or  development  of  dissection. 

DISCUSSION 

Mechanical  declotting  of  thrombosed  hemodi- 
alysis shunts  with  or  without  thrombolytics, 
provides  an  effective,  reliable,  rapid,  and  safe 
way  to  restore  flow  to  hemodialysis  accesses. 
Patients  treated  in  this  fashion  can  be  immedi- 
ately dialyzed  practically  eliminating  the  need 
for  hospitalization,  reducing  placement  of  tem- 
porary hemodialysis  catheters  with  its  associ- 
ated complications,  and  decreasing  morbidity 
and  costs. 

Our  experience  with  several  variations  of  a 
percutaneous  declotting  procedure  shows  that 
acute  shunt  patency  can  be  achieved  with  reli- 
able and  reproducibly  successful  results.  There 
was  no  appreciable  difference  in  outcome  be- 
tween native  and  synthetic  shunts.  Our  success 
and  complication  rates  were  similar  to  other  se- 
ries reported  in  the  literature.6"9  Our  only  instance 
of  arterial  embolization  occurred  early  in  our 
series  and  was  the  result  of  a forceful  injection 
of  contrast  material  into  the  shunt  for 
angiographic  evaluation  of  our  results.  From 
then  on,  we  avoided  performing  direct  contrast 
injection  into  the  shunt.  The  lack  of  stenosis  data 
in  27%  of  our  patients  reflects  the  fact  that  some 
of  the  occlusions  were  due  to  other  factors  such 
as  extrinsic  compression,  low  cardiac  output, 
dehydration,  and  hypotension.  Additionally, 
because  stenoses  were  identified  only  by  the 
occurrence  of  balloon  deformity  during 
angioplasty,  soft  stenotic  lesions  may  not  have 
been  recognized.  Interestingly,  we  found  no  dif- 
ference in  success  rate  between  those  throm- 


bosed shunts  receiving  thrombolysis  and  those 
treated  without  thrombolysis.  Therefore,  we  sug- 
gest that  treatment  of  thrombosed  shunts  with 
mechanical  disruption  of  the  clot  and 
angioplasty  should  be  the  primary  therapeutic 
modality  and  that  use  of  thrombolytics  should 
be  reserved  to  those  cases  where  a significant 
amount  of  residual  clot  is  identified.  In  this  fash- 
ion, the  potential  complications  of  thrombolysis 
are  largely  avoided  and  hemostasis  post  proce- 
dure is  easily  accomplished. 

REFERENCES 

1.  Wilson  SE.  Complications  of  vascular  access  pro- 
cedures. In:  Wilson  SE,  Owens  ML  (editors).  Vas- 
cular Access  Surgery.  Chicago:  Year  Book  Medical 
Publishers;1980:185. 

2.  Lazarus  JM,  Huang  WH,  Lew  NL,  et  al.  Contribu- 
tion of  vascular  access-related  disease  to  morbid- 
ity of  hemodialysis  patients.  In:  Henry  ML, 
Lerguson  R (editors).  Vascular  access  for  hemodi- 
alysis. 

3.  Port  FK.  The  end-stage  renal  disease  program: 
trends  over  the  past  18  years.  Am  J Kidney  Dis  1992; 
20(suppl):3-7. 

4.  Kanterman  RY,  Vesely  TM,  Pilgram  TK,  et  al.  Di- 
alysis access  grafts:  anatomic  location  of  venous 
stenosis  and  results  of  angioplasty.  Radiology 
1995;195:135-139. 

5.  Kherlakian  GM,  Roederscheimer  LR,  Arbaugh  JJ, 
et  al.  Comparison  of  autogenous  fistula  versus  ex- 
panded polytetrafluoroethylene  graft  fistula  for 
angioaccess  in  hemodialysis.  Am  J Surg 
1986;152:238-243. 

6.  Beathard  GA,  Welch  BR,  Maidment  HJ.  Mechani- 
cal thrombolysis  for  the  treatment  of  thrombosed 
hemodialysis  access  grafts.  Radiology  1996;200:711- 
716. 

7.  Trerotola  SO,  Lund  GB,  Scheel  PJ,  et  al.  Thrombosed 
dialysis  access  grafts:  percutaneous  mechanical 
declotting  without  urokinase.  Radiology 
1994;191:721-726. 

8.  Middebrook  MR,  Amygdalos  MA,  Soulen  MC,  et 
al.  Thrombosed  hemodialysis  grafts:  percutaneous 
balloon  declotting  versus  thrombolysis.  Radiology 
1995;196:73-77. 

9.  Trerotola  SO,  Vesely  TM,  Lund  GB,  et  al.  Treatment 
of  thrombosed  hemodialysis  grafts:  Arrow-Trerotola 
percutaneous  thrombolytic  device  versus  pulse- 
spray  thrombolysis.  Arrow-Trerotola  Thrombolytic 
Device  Clinical  Trial.  Radiology  1998;202:403-414. 


J La  State  Med  Soc  VOL  152  November  2000  561 


10.  Castaneda  F,  Wyffelsm  PL,  Patel  JC,  et  al.  New 
thrombolytic  brush  catheter  in  thrombosed 
polytetrafluoroethylene  dialysis  grafts:  preclinical 
animal  study.  / Vase Interv Radiol  1998;9:793-798. 


Dr  Tan  is  a Fellow,  Section  of  Cardiology, 
at  Louisiana  State  University  School  of  Medicine, 
New  Orleans,  Louisiana. 

Dr  Yount  is  a Cardiologist  at  Touro  Infirmary, 
and  Assistan  t Clinical  Professor  of  Medicine 
at  Louisiana  State  University  School  of Medicine, 
New  Orleans,  Louisiana . 

Dr  Quintal  is  an  Interventional  Cardiologist 
a t Touro  Infirmary,  and  Associa  te  Clinical 
Professor  of  Medicine  at  Louisiana  State  University  School 
of  Medicine  and  Tulane  University  School  of  Medicine, 

New  Orleans,  Louisiana. 


562  J La  State  Med  Soc  VOL  152  November  2000 


Synovial  Cyst  of  Lumbar  Spine 
Presenting  as  Disc  Disease: 

A Case  Report  and  Review  of  Literature 


Praveen  Reddy,  MD;  Satish  Satyanarayana,  MD; 
and  Anil  Nanda,  MD 


Synovial  cysts  most  commonly  involve  the  joints  of  the  extremities.  These  cysts  are  rarely 
found  in  the  spinal  canal  or  the  vertebral  facet  joints.  However,  if  manifested  as  such, 
they  can  pose  serious  diagnostic  and  therapeutic  problems  due  to  the  presentation,  which 
most  often  resembles  nerve  root  or  spinal  cord  compression.  Acute  low  back  pain  and 
radiculopathy  are  often  attributed  to  a herniated  nucleus  pulposus.  This  paper  presents  a 
case  of  synovial  cyst  in  a 62-year-old  woman  with  a 2-year  history  of  refractory  low  back 
pain  with  distal  radiation.  A facet  joint  cyst  was  encountered  upon  neuroimaging,  result- 
ing in  excision  of  the  cyst.  In  this  report,  we  discuss  the  differential  diagnosis  of  synovial 
cysts,  the  role  of  computed  tomography  and  magnetic  resonance  imaging  in  the  diagno- 
sis, and  treatment  options  for  this  uncommon  entity. 


Synovial  cysts  are  well  recognized  in  neu- 
rological surgery  but  are  an  infrequent 
cause  of  nerve  root  or  spinal  cord  com- 
pression. These  cysts,  sometimes  called  ganglia, 
are  most  commonly  found  in  the  extremities, 
specifically  at  the  wrists  and  knees.  However, 
they  can  be  found  associated  with  any 
diarthrodial  joint  in  the  body.  Because  the  lum- 
bar region  is  affected  in  most  of  the  cases,  pa- 
tients usually  present  with  manifestations  of  ei- 


ther sciatica  or  femoral  nerve  compression.  The 
clinical  course  can  vary  depending  on  the  size 
and  location  of  the  cyst.  Complete  recovery  is 
possible  with  either  a conservative  approach  or 
with  surgical  excision  of  the  cyst. 

CASE  REPORT 

A 62-year-old  woman  presented  with  a 2-year 
history  of  low  back  pain  radiating  down  the  right 


J La  State  Med  Soc  VOL  152  November  2000  563 


lower  extremity.  The  radiating  pain  was  not  re- 
sponsive to  conservative  therapy  There  was  no 
associated  tingling  or  numbness  and  the  patient 
denied  any  bowel  or  bladder  disturbances.  Neu- 
rological examination  revealed  good  motor 
strength  in  both  upper  and  lower  extremities 
with  normal  deep  tendon  reflexes  and  down 
going  toes.  The  straight  leg  raising  test  was  posi- 
tive on  the  right  side;  however,  right  side  L-5 
dermatomal  distribution  was  impaired,  as  indi- 
cated by  decreased  pinprick  perception.  MRI  of 
the  lumbar  spine  revealed  an  extradural  right 
posterolateral  mass  encroaching  on  the  thecal  sac 
at  L4-5  level  (Figure).  This  mass  was  later  iden- 
tified as  a synovial  cyst  on  the  right  L4-5  facet 
joint.  Minimal  spondylosis  and  disc  herniations 
were  also  noted  at  the  LI -2  level. 

Conservative  management  for  3 to  4 months 
was  unsuccessful,  and  the  patient  developed 
neurological  deficit.  After  explaining  the  risks 
and  benefits  of  the  surgery,  a complete  laminec- 
tomy at  L4  level  with  bilateral  foraminotomies 
was  performed.  An  extradural  cystic  mass  ad- 
herent to  dura  was  seen  and,  under  microscopic 
magnification,  the  mass  was  decompressed  and 
excised  completely.  The  patient  tolerated  surgery 
well  and  showed  marked  postoperative  neuro- 
logical improvement.  Histopathology  revealed 
a benign  cyst  lined  with  synovial  epithelium 
consistent  with  synovial  cyst.  At  1-year  follow- 
up, the  patient  remained  symptom  free. 

DISCUSSION 

Baker  first  described  synovial  cyst  in  1877  as  be- 
ing secondary  to  processes  occurring  within  an 
adjacent  degenerated  joint.1  The  first  case  report 
on  symptomatic  lumbar  facet  joint  synovial  cyst 
was  published  in  1968  by  Kao  et  al.2 

Incidence 

Lumbar  synovial  cyst  is  more  common  than  pre- 
viously reported.  A review  of  the  literature  re- 
vealed that  approximately  115  cases  of  facet  joint 
synovial  cysts  of  the  entire  spine  have  been  re- 
ported to  date.  The  incidence  of  synovial  cyst  is 
apparently  on  the  rise,  possibly  due  to  the  ad- 


Figure.  Sagittal  MRI  of  the  lumbar  sacral  spine  (T1 
and  T2  weighted,  respectively)  showing  the  lesion  op- 
posite L4-5. 


vent  of  high-resolution  computed  tomography 
and  magnetic  resonance  imaging  as  well  as  an 
increase  in  the  average  life  span  of  the  popula- 
tion.3 Synovial  cyst  occurs  mainly  in  elderly  in- 
dividuals, suggesting  a link  with  degenerative 
joint  disease. 

Etiology 

The  exact  etiology  of  synovial  cyst  is  unknown. 
The  hypothesis  of  protrusion  of  synovial  lining 
through  a defect  in  the  joint  capsule,  possibly 
resulting  from  trauma  or  degeneration,  is  the 
most  commonly  accepted  probability.3  Other 
possible  causes  include  developmental  arrest  of 
the  synovial  tissue,  metaplasia  of  pleura-poten- 
tial mesenchymal  cells,  myxoid  degeneration  of 
the  collagen  tissue,  and  increased  production  of 
hyaluronic  acid  by  fibroblasts  due  to  recurring 
trauma.  These  cysts  are  generally  thought  to  rep- 
resent a continuum  of  degeneration  and  cystic 
formation. 

Pathology 

Facet  cysts  have  been  separated  into  two  distinct 
types:  "synovial"  and  "ganglionic".  Most  au- 
thors use  these  terms  interchangeably  because 


564  J La  State  Med  Soc  VOL  152  November  2000 


the  clinical  presentation,  diagnosis,  and  treat- 
ment are  identical.  Furthermore,  the  distinction 
between  the  two  types  is  of  pathological  inter- 
est only.  Synovial  cysts  are  lined  by  pseudo- 
stratified  columnar  synovial  cell  lining  and  con- 
tain thin,  straw-colored  fluid  with  no  inflamma- 
tory changes.  Ganglion  cysts  have  no  synovial 
lining  and  are  filled  with  myxoid  gelatinous 
material.  An  occasional  specimen  may  contain 
hemosiderin,  which  is  consistent  with  traumatic 
origin  of  the  cyst. 

The  most  common  site  for  facet  cyst  forma- 
tion is  the  lumbar  region,  specifically  between 
L4-5,  which  is  also  associated  with  the  greatest 
range  of  movement.  Literature  supports  evi- 
dence that  the  cervical  spine  is  the  least  com- 
mon area  for  facet  cysts.  Cases  have  been  re- 
ported in  which  the  cyst  is  attached  to  almost 
every  structure  in  the  spinal  canal,  including  the 
disc  itself. 

Clinical  Features 

There  is  no  diagnostic  physical  finding  or  clini- 
cal feature  of  a synovial  cyst.  Most  patients 
present  with  radicular  pain  with  or  without  neu- 
rologic deficit,  neurogenic  claudication,  or  limi- 
tation of  back  motion  and  positive  straight  leg 
raising.  Myelopathy  is  minimal  or  absent.  Acute 
low  back  pain  or  an  acute  exacerbation  of  exist- 
ing chronic  back  pain  was  reported  following 
hemorrhage  into  the  cyst. 

Diagnosis 

With  low  back  pain  being  the  most  common  pre- 
senting complaint,  synovial  cysts  should  always 
be  differentiated  from  infectious  processes 
(diskitis,  epidural  abscess,  spinal  osteomyelitis), 
degenerative  disease  (herniated  nucleus 
pulposus,  spondylolisthesis,  spinal  stenosis), 
and  pathological  conditions  such  as  metastases. 
CT  and,  more  recently,  MRI  are  the  diagnostic 
imaging  studies  of  choice.  CT  findings  of  a lum- 
bar synovial  cyst  are  characteristic,  as  described 
by  Hemminghytt  et  al  in  1982,  and  generally 
show  a well-defined  rounded  mass  with  a calci- 
fied contour  originating  from  the  facet.4  MRI 
reveals  a well-defined  mass  with  variable  inten- 


sity on  ^-weighted  images  and  hyperintensity 
on  T2- weighted  images.5 

Treatment 

Synovial  cysts  can  be  treated  either  conserva- 
tively or  surgically.  Asymptomatic  synovial  cysts 
detected  incidentally  on  radiological  studies  are 
managed  conservatively.  In  the  absence  of  sig- 
nificant neurologic  deficit,  even  the  symptom- 
atic synovial  cyst  should  be  given  a trial  of  con- 
servative management.  Spontaneous  remission 
of  the  symptoms  has  been  documented  in  the 
literature,  both  as  a result  of  and  by  the  use  of 
an  external  lumbar  spinal  brace.  Such  an  out- 
come suggests  the  possibility  of  spontaneous 
collapse  of  the  cyst.4  Minimally  invasive  micro- 
surgical  needle  aspiration  of  the  cysts  has  been 
done  in  some  cases  with  a very  satisfactory  suc- 
cess rate.  However,  the  rate  of  recurrence  is  un- 
known. The  use  of  radiologic-guided  percuta- 
neous injection  of  corticosteroids  into  the  cysts 
has  also  been  reported  in  the  radiological  litera- 
ture with  satisfactory  results.6 

Overall,  surgical  decompression  and  exci- 
sion of  the  cyst  remains  the  definitive  treatment 
of  choice.  A conservative  approach  should  be  at- 
tempted initially  since  most  patients  presenting 
with  this  entity  are  at  an  advanced  age.  In  the 
elderly,  laminectomy  and  foraminotomy  proce- 
dures, though  generally  well  tolerated,  cause 
significant  postoperative  pain  and  may  require 
prolonged  hospitalization.  In  a case  series  re- 
ported by  Charest  et  al,  decompressive  micro- 
surgical  procedures  were  very  successful  and 
yielded  good  results.5  Therefore,  surgery  should 
be  undertaken  only  in  intractable  cases  that  do 
not  respond  to  conservative  management. 

CONCLUSION 

Intraspinal  synovial  cysts  are  uncommon  benign 
lesions  that  are  associated  with  degenerative 
disease  of  the  spine.  They  are  most  commonly 
located  in  the  lumbar  region  (L4-5).  There  are 
no  distinctive  physical  findings  diagnostic  of 
synovial  cysts  and  high  resolution  CT  or  MRI 
are  the  imaging  modalities  of  choice.  Though 


J La  State  Med  Soc  VOL  152  November  2000  565 


some  patients  respond  to  conservative  manage- 
ment; surgical  decompression  and  excision  of  the 
cysts  may  be  indicated  in  refractory  cases.  How- 
ever, in  elderly  patients,  minimally  invasive  pro- 
cedures should  always  be  attempted  before  opt- 
ing for  major  surgical  excision. 

REFERENCES 

1 . Baker  WM.  Formation  of  abnormal  synovial  cysts 
in  connection  with  the  joints.  St  Bartholomew's  Hosp 
Rep  1985;21:177-190. 

2.  Kao  C,  Uihlein  A,  Bickel  W,  et  al.  Lumbar  intraspi- 
nal  extradural  ganglion  cyst.  / Neurosurgery 
1968;29:168-172. 

3.  Eyster  EF,  Scott  WR.  Lumbar  synovial  cysts:  report 
of  eleven  cases.  Neurosurgery  1989;24:112-115. 

4.  Hemminghytt  S,  Daniels  DL,  Williams  AL,  et  al. 
Intraspinal  synovial  cysts:  natural  history  and  di- 
agnosis by  CT.  Radiology  1982;145:377-378. 

5.  Charest  DR,  Kenny  BG.  Radicular  pain  caused  by 
synovial  cyst:  an  undiagnosed  entity  in  the  elderly. 
J Neurosurg  2000;92(1  suppl):57-60. 

6.  Abrahams  JJ,  Wood  GW,  Eames  FA,  et  al.  CT- 
guided  needle  aspiration  biopsy  of  an  intraspinal 
synovial  cyst  (ganglion):  case  report  and  review  of 
the  literature.  AJNR  1988;9:398-400. 


Dr  Reddy  is  a research  fellow 
of  the  Department  of  Neurosurgery 
Louisiana  State  University  Health  Sciences  Center, 

Shreveport,  Louisiana. 

Dr  Satyanarayana  is  a research  fellow 
of  the  Departmen  t of  Neurosurgery, 
Louisiana  State  University  Health  Sciences  Center, 

Shreveport,  Louisiana. 

DrNanda  is  Professor  and  Chairman 
of  the  Department  of  Neurosurgery, 
Louisiana  State  University  Health  Sciences  Center, 

Shreveport,  Louisiana. 


566  J La  State  Med  Soc  VOL  152  November  2000 


Higher  Risk  of  HIV  Transmission 
During  Trauma  Resuscitations 


Atul  K.  Madan,  MD;  Kelly  J.  McKinell,  MPH;  Stephanie  J.  Posner,  MPH; 
C.  Greg  Gaines,  PhD;  and  Lewis  M.  Flint,  MD 


Despite  an  appreciation  of  the  potential  for  blood  borne  pathogen  exposure,  compliance 
of  universal  precautions  is  low.  While  reports  of  HIV  positive  rates  in  trauma  patients 
have  varied  from  0.15%  to  7.8%,  the  estimated  prevalence  of  HIV  in  Louisiana  is  0.32%. 
We  made  use  of  two  unique,  complimentary  data  sources:  the  Trauma  Registry  and  the 
HIV / AIDS  Reporting  System  database  of  known  HIV  positive  patients  to  estimate  the 
relative  prevalence  of  HIV  which  may  indicate  an  increase  risk  of  blood  borne  pathogen 
transmission  to  health  care  workers  during  trauma  resuscitations.  In  one  year,  1031/1159 
patients  were  evaluated  from  the  Trauma  Registry  Database  and  22  similar  patients  (2.13%) 
were  found  in  both  the  Trauma  Registry  and  the  HIV / AIDS  Reporting  System  Database. 
Our  prevalence  is  an  indicator  of  the  minimum  risk  since  it  is  based  on  only  reported  cases 
of  HIV  and  justifies  intensification  of  education  and  enforcement  of  the  practice  of  uni- 
versal precautions. 


The  hectic  nature  of  trauma  resuscitations 
leads  to  a greater  opportunity  for  trans- 
mission of  blood  borne  pathogens.  Thus, 
the  Centers  for  Disease  Control  and  Prevention, 
the  American  College  of  Surgeons  Committee 
on  Trauma,  and  the  American  College  of  Emer- 
gency Physicians  all  have  advocated  policies 
regarding  universal  precautions  especially  in 
situations  such  as  trauma  resuscitations.  In  fact, 
hospital  policies  mandate  universal  precautions. 


Despite  these  policies,  many  health  care  work- 
ers (HCWs)  seem  not  to  take  full  advantage  of 
universal  precautions.1'6 

While  the  lack  of  compliance  of  HCWs  is  a 
multifactorial  process,  benefit  may  be  derived 
from  documenting  the  prevalence  of  blood  borne 
pathogens  in  trauma  populations.  Since  at  least 
one  investigation  showed  that  many  underesti- 
mated the  risk  of  blood  borne  pathogens/ 
knowledge  of  risk  may  help  persuade  a more 


J La  State  Med  Soc  VOL  152  November  2000  567 


universal  use  of  universal  precautions.  Utiliz- 
ing two  unique,  complimentary  data  sources 
(the  Trauma  Registry  [TR]  and  the  HIV/ AIDS 
Reporting  System  [HARS]  database  of  known 
HIV  positive  patients),  this  investigation  deter- 
mines the  prevalence  of  HIV  in  trauma  patients 
compared  to  the  general  population  in  order  to 
demonstrate  an  increased  potential  of  blood 
borne  pathogen  transmission  to  HCWs  during 
trauma  resuscitations. 

MATERIALS  AND  METHODS 

Over  a 1-year  period  (July  1996  to  June  1997),  all 
patients  over  the  age  of  18  sustaining  life-threat- 
ening injuries  presenting  to  the  Medical  Center 
of  Louisiana  at  New  Orleans  (Charity  Hospital) 
were  identified  by  our  Trauma  Registry.  The 
Medical  Center  of  Louisiana  at  New  Orleans  is 
the  only  American  College  of  Surgeons  verified 
Level  1 trauma  center  in  our  area.  Life-threaten- 
ing injuries  were  identified  by  pre-hospital  per- 
sonnel and  emergency  room  staff  physicians  per 
a protocol  approved  by  the  trauma  committee. 
While  data  concerning  all  trauma  patients  are 
collected  by  our  Trauma  Registry,  this  investi- 
gation focused  strictly  on  those  patients  who 
sustained  life-threatening  injuries  and  where 
Advanced  Trauma  Life  Support  protocol  was 
immediately  initiated  by  the  trauma  surgery 
team.  Patients  with  incomplete  data  were  not 
included.  Patients  who  were  involved  in  more 
than  one  trauma  were  only  counted  once. 

In  collaboration  with  the  Centers  for  Disease 
Control  and  Prevention  (CDC),  the  Louisiana 
Office  of  Public  Health  (OPH)  maintains  an  ac- 
tive surveillance  system  on  reported  HIV / AIDS 
cases.  Data  from  HARS  are  used  to  plan  and 
implement  HIV  prevention  and  service  pro- 
grams in  Louisiana.  Case  information  is  obtained 
by  epidemiologists  in  contact  with  health  care 
providers  and  testing  facilities  as  well  as  through 
laboratory  reporting  of  test  results  diagnostic  of 
HIV  infection  or  AIDS.  HIV / AIDS  reporting  by 
these  providers  and  facilities  is  required  by  the 
state  sanitary  code. 

Using  Microsoft  Access  97,  a matching  pro- 
gram was  used  to  determine  patients  who  were 


in  both  the  TR  database  and  the  HARS  database. 
Charts  were  reviewed  for  verification  by  HIV / 
AIDS  surveillance  staff.  Any  documentation  of 
known  or  suspected  HIV  infection  during  the 
trauma  resuscitation  was  noted  as  well.  Chi- 
squared  analysis  was  used  for  statistical  analy- 
sis with  GraphPAD  InStat  Version  1.12a. 

RESULTS 

In  1 year,  1159  patients  presented  to  the  Medical 
Center  of  Louisiana  at  New  Orleans  with  life- 
threatening  injuries,  and  1031  were  evaluated. 
There  were  22  similar  patients  (2.13%)  found  in 
both  the  TR  and  the  HARS  Database.  The  esti- 
mated prevalence  of  HIV  in  the  state  of  Louisi- 
ana is  0.32%.8  The  Figure  displays  the  estimated 
prevalence  of  HIV  in  specific  cohorts  compared 
to  the  overall  population. 

The  cohort  of  patients  who  sustained  pen- 
etrating injuries  was  eight  times  more  likely  to 
have  HIV  than  the  overall  state  population  (P  < 
0.0001).  Interestingly,  even  the  blunt  trauma  pa- 
tients who  had  the  lowest  percentage  of  HIV 
infection  had  a statistically  significant  higher  rate 
of  HIV  infection  when  compared  to  the  overall 
state  population  (P  < 0.0001).  The  HIV  status  of 
injured  patients  was  known  to  the  HCW  par- 
ticipating in  the  resuscitation  in  only  7/22  pa- 
tients (32%). 

DISCUSSION 

Our  data  demonstrate  that  the  prevalence  of  HTV 
infection  is  higher  in  our  trauma  patients.  HCWs 
need  to  realize  that  trauma  patients  pose  a higher 
threat  to  blood  borne  pathogen  transmission. 
While  our  overall  percentage  may  seem  low 
(2.13%),  true  prevalence  is  assumed  to  be  higher. 
The  true  HIV  prevalence  could  be  measured  but 
this  is  not  cost  effective.9  Also,  while  the  rate  of 
HIV  may  be  considered  relatively  low,  the  rate 
of  hepatitis  B and  C is  most  likely  much  higher. 
Because  of  the  complexities  involved  in  the  re- 
porting of  HIV  infection,  the  overall  state  preva- 
lence of  HIV  infection  is  only  an  estimate;  it  is, 
therefore,  very  approximate  and  statistically 
imprecise.  This  estimate  is,  however,  lower  than 
our  reported  prevalence  of  HIV  infection.  Thus, 


568  J La  State  Med  Soc  VOL  152  November  2000 


the  eight  times  higher  risk  in  our  penetrating 
trauma  population  for  blood  borne  pathogen 
transmission  is  most  likely  an  underestimation. 

Also,  less  than  one  third  of  our  patients  who 
were  known  to  have  HIV  infection  were  identi- 
fied as  such  during  their  trauma  resuscitation. 
Since  trauma  resuscitations  are  often  hectic  en- 
vironments in  which  procedures  are  done 
emergently,  the  chance  for  blood  borne  patho- 
gen transmission  is  increased.  Sharp  instruments 
and  blood  exposure  provide  dangerous  occupa- 
tional hazards  to  the  HCWs  especially  in  situa- 
tions in  which  HIV  infection  is  not  known.  Even 
if  it  were  possible  to  ascertain  HIV  risk  factors 
in  trauma  patients,  Rudolph  et  al  showed  that 
they  do  not  reliably  identify  patients  with  HIV 
infection.10  While  most  HCWs  would  agree  that 
universal  precautions  are  needed  universally. 


knowledge  of  HIV  infection  in  a patient  prob- 
ably would  increase  caution  when  dealing  with 
sharps  as  well  as  blood.  However,  in  trauma  re- 
suscitations, most  HCWs  are  unaware  of  the  HTV 
status,  thus  often  producing  a laxity  in  univer- 
sal precautions. 

The  increased  prevalence  in  blood  borne 
pathogens  in  trauma  patients  may  be  due  to 
multiple  factors.  At  our  institution,  trauma  pa- 
tients have  been  shown  to  have  a relatively  high 
prevalence  of  substance  use.11  This  prevalence 
of  substance  use  has  been  documented  by  other 
investigators  as  well.12'19  Substance  use  is  a risk 
factor  for  HIV,  hepatitis  B,  and  hepatitis  C not 
only  through  direct  inoculation  by  use  of  dirty 
needles  but  also  by  inducing  an  altered  senso- 
rium  which  could  lead  to  other  high-risk  behav- 
iors. In  other  words,  when  patients  have  im- 


> 


O 

0 

Ui 

0 

*-» 

c 

0 

G 

L. 

0 

CL 


* 


3.00% 


2.52% 


2.00% 

1.00% 

0.00% 


* 


1.19% 


Penetrating  Blunt  Trauma 
Trauma 


* 


2.13% 


Total  Trauma  Overall  State 
HIV  Prevalence 


*p  < 0.0001  compared  to  Overall  State  HIV  Prevelance 


Figure.  Percentage  of  HIV  by  Population.  Proportions  of  reported  HIV  infection  in  trauma  patients  compared 
to  estimated  state  prevalence.  The  proportions  of  reported  HIV  infection  are  statistically  higher  in  the  trauma 
population,  especially  in  the  penetrating  trauma  population. 


J La  State  Med  Soc  VOL  152  November  2000  569 


REFERENCES 


paired  judgment  secondary  to  substance  use, 
their  likelihood  of  acting  on  risk  taking  behav- 
iors (eg  unprotected  sexual  activity)  increases. 
Since  the  lifestyle  associated  with  substance  use 
can  lend  itself  to  a lifestyle  associated  with 
trauma,20  the  same  lifestyle  can  lend  itself  to  other 
high-risk  behaviors.  These  reasons  may  contrib- 
ute to  why  trauma  victims  often  have  a higher 
chance  of  HTV,  hepatitis  B,  and  hepatitis  C. 

Our  HIV  infection  prevalence  was  well  in  the 
range  reported  by  others  (0.15%  to  7.8%).1/9/10,21'24 
In  fact,  Kelen  et  al  showed  an  increase  of  HIV 
infection  from  3.0%  to  7.8%  over  a 1-year  period 
at  the  Johns  Hopkins  Hospital.21  However,  since 
the  prevalence  of  HIV  is  lower  than  that  of  most 
other  blood  borne  pathogens,  the  risk  of  hepati- 
tis is  even  higher.  In  fact,  Caplan  et  al  demon- 
strated that  one  fourth  of  their  trauma  patients 
had  a potential  transmissible  agent.23  Despite  this 
increased  risk,  HCWs  have  low  compliance  with 
universal  precautions  in  the  emergency  room.1'6 

Reasons  for  laxity  in  compliance  with  uni- 
versal precautions  must  be  explored.  It  has  been 
shown  that  many  HCWs  underestimate  the  risk 
of  blood  borne  pathogens7  and  overestimate 
their  compliance  with  universal  precautions.3 
Education  of  these  HCWs  may  help  increase 
compliance  with  universal  precautions.  In  fact, 
Kristensen  et  al  showed  that  HCWs  who  under- 
stood and  complied  with  universal  precautions 
had  lower  rates  of  contact  with  blood.23  Using 
the  same  reasoning,  HCWs  who  understand  the 
higher  risk  of  blood  borne  transmission  may 
actually  comply  with  universal  precautions 
more  often.  Both  this  risk  and  the  fact  that  the 
true  status  of  most  patients  is  not  known  dur- 
ing trauma  resuscitations  justify  intensification 
of  education  and  enforcement  of  the  practice  of 
universal  precautions. 

ACKNOWLEDGMENT 

The  authors  would  like  to  thank  the  Medical 
Center  of  Louisiana  at  New  Orleans  (Charity 
Campus)  Trauma  Registry  for  their  assistance. 


1.  Kelen  G,  DiGiovanna  T,  Bisson  L,  et  al.  Human 
immunodeficiency  virus  infection  in  emergency 
department  patients:  epidemiology,  clinical  presen- 
tations, and  risk  to  health  care  workers:  The  Johns 
Hopkins  Experience.  JAMA  1989;262:516-522. 

2.  Hammond  J,  Eckes  J,  Gomez  G,  et  al.  HIV,  trauma, 
and  infection  control:  universal  precautions  are 
universally  ignored.  / Trauma  1990;30:555-561. 

3.  Henry  K,  Campbell  S,  Maki  M.  A comparison  of 
observed  and  self-reported  compliance  with  uni- 
versal precautions  among  emergency  department 
personnel  at  a Minnesota  public  teaching  hospital: 
implications  for  assessing  infection  control  pro- 
grams. Ann  EmergMed  1992;21:940-946. 

4.  Nelsing  S,  Nielson  T,  Nielson  J.  Noncompliance 
with  universal  precautions  and  the  associated  risk 
of  mucocutaneous  blood  exposure  among  Danish 
physicians.  Infect  Control  Hosp  Epidemiol 
1997;18:692-698. 

5.  Baraff  L,  Talan  D.  Compliance  with  universal  pre- 
cautions in  a university  hospital  emergency  depart- 
ment. Ann  EmergMed  1989;18:654-657. 

6.  Evanoff  B,  Kim  L,  Mutha  S,  et  al.  Compliance  with 
universal  precautions  among  emergency  depart- 
ment personnel  caring  for  trauma  patients.  Ann 
EmergMed  1999;33:160-165. 

7.  Patterson  J,  Novak  C,  Mackinnon  S,  et  al.  Surgeon's 
concern  and  practices  of  protection  against 
bloodbome  pathogens.  Ann  Surg  1998;228:266-272. 

8.  HIV/ AIDS  Annual  Report.  Louisiana  Department 
of  Health  and  Hospitals,  Office  of  Public  Health, 
Epidemiology  Section.  1996. 

9.  Mullins  J,  Harrison  P.  The  questionable  utility  of 
mandatory  screening  for  the  human  immunodefi- 
ciency virus.  Am  J Surg  1993;166:676-679 . 

10.  Rudolph  R,  Bowen  D,  Boyd  C,  et  al.  Seroprevalence 
of  human  immunodeficiency  virus  in  admitted 
trauma  patients  at  a southeastern  metropolitan/ 
rural  trauma  center.  Am  Surg  1993;59:384-387. 

11.  Madan  A,  Yu  K,  Beech  D.  Alcohol  and  drug  use  in 
victims  of  life-threatening  trauma.  / Trauma 
1999;47:568-571. 

12.  Beech  D,  Mercadel  R.  Correlation  of  alcohol  intoxi- 
cation with  life-threatening  assaults.  / Natl  Med 
Assoc  1998;90:761-764. 

13.  Cornwell  E,  Belzberg  H,  Velmahos  G,  et  al.  The 
prevalence  and  effect  of  alcohol  and  drug  abuse 
on  cohort-matched  critically  ill  patients.  Am  Surg 
1998;64:461-465. 

14.  Goodman  R,  Mercy  J,  Loya  F,  et  al.  Alcohol  use  and 
interpersonal  violence:  alcohol  detected  in  homi- 
cide victims.  Am  J Public  Health  1986;76:144-149. 


570  J La  State  Med  Soc  VOL  152  November  2000 


15.  Meyers  H,  Zepeda  S,  Murdock  M.  Alcohol  and 
trauma.  West  J Med  1990;153:149-153. 

16.  Rivara  R,  Jurkovick  G,  Gurney  J,  et  al.  The  magni- 
tude of  acute  and  chronic  alcohol  abuse  in  trauma 
patients.  Arch  Surg  1993;128:907-913. 

17.  Rivara  F,  Mueller  B,  Fligner  C,  et  al.  Drug  use  in 
trauma  victims.  / Trauma  1989;29:462-470. 

18.  Sloan  E,  Zalenski  R,  Smith  R,  et  al.  Toxicology 
screening  in  urban  trauma  patients:  drug  preva- 
lence and  its  relationship  to  trauma  severity  and 
management.  / Trauma  1989;29:1647-1653. 

19.  Vanek  V,  Dickey-White  H,  Signs  S,  et  al.  Concur- 
rent use  of  cocaine  and  alcohol  by  patients  treated 
in  the  emergency  department.  Ann  Emerg  Med 
1996;28:508-514. 

20.  Dukarm  C,  Byrd  R,  Auinger  P,  et  al.  Illicit  substance 
use,  gender,  and  the  risk  of  violent  behavior  among 
adolescents.  Arch  PediatrAdolescMed  1996;150:797- 
801. 

21.  Kelen  G,  Fritz  S,  Qaquish  B,  et  al.  Substantial  in- 
crease in  human  immunodeficiency  virus  (HIV-1) 
infection  in  critically  ill  emergency  patients:  1986 
and  1987  compared.  Ann  Emerg  Med  1989;18:378- 
382. 

22.  Rhee  K,  Albertson  T,  Kizer  K,  et  al.  The  HIV-1 
seroprevalence  rate  of  injured  patients  admitted 
through  California  emergency  departments.  Ann 
Emerg  Med  1991;20:969-972. 

23.  Caplan  E,  Preas  M,  Kerns  T,  et  al.  Seroprevalence 
of  human  immunodeficiency  virus,  hepatitis  B vi- 
rus, hepatitis  C virus,  and  rapid  plasma  reagin  in  a 
trauma  population.  / Trauma  1995;39:533-538. 


24.  Nagachinta  T,  Gold  C,  Cheng  F,  et  al.  Unrecognized 
HIV-1  infection  in  inner-city  hospital  emergency  de- 
partment patients.  Infect  Control  Hosp  Epidemiol 
1996;17:174-177. 

25.  Kristensen  M,  Wernberg  N,  Anker-Moller  E. 
Healthcare  workers7  risk  of  contact  with  body  flu- 
ids in  a hospital:  the  effect  of  complying  with  the 
universal  precautions  policy.  Infect  Control  Hosp 
Epidemiol  1992;13:719-724. 


Dr  Madan  is  a chief  surgical  resident  at  the 
Department  of  Surgery,  Tulane  University  School  of 
Medicine,  New  Orleans,  Louisiana. 

Mr  McKinell  is  employed  by  the  Louisiana  HTV/AJDS 
Sur\TeiIlance  Program,  New  Orleans,  Louisiana. 

Ms  Posner  is  the  Analysis  and  Dissemination  Coordina- 
tor for  the  Louisiana  HTV/AJDS  Sur\reUlance  Program, 

New  Orleans,  Louisiana. 

Dr  Gaines  is  employed  by  the  Louisiana  HTV/AJDS 
Surmillance  Program,  New  Orleans,  Louisiana. 

Dr  Flint  is  Professor  of  Surgery  and  Director  of  Tra  uma 
and  Surgical  Critical  Care,  Department  of  Surgery, 
University  of  South  Honda,  Tampa,  Honda. 


J La  State  Med  Soc  VOL  152  November  2000  57 1 


A Prescription  for  the  21st  Century 
T.E.A.C.H.  Our  Patients 


Daniel  R.  Bronfin,  MD 


It  was  Monday  morning  in  my  General  Pe- 
diatrics clinic.  "Be  prepared",  my  nurse 
warned,  "the  dad  in  the  first  room  is  really 
upset  that  he  was  not  given  antibiotics  over  the 
phone  for  his  child's  cold."  I turned  to  the  medi- 
cal student  with  whom  I was  working  that 
morning  and  asked  her  to  think  about  the  up- 
coming encounter  and  to  determine  how  we 
might  satisfy  the  needs  and  wishes  of  this  par- 
ent while  not  compromising  appropriate  care 
of  the  child.  Additionally,  I asked  her  to  keep  in 
mind  that  antibiotics  do  not  cure  viral  infec- 
tions— a simple  microbiologic  truth,  yet  one  that 
many  clinicians  agonize  over  on  a daily  basis. 

The  child  clearly  had  a mild  cold,  a viral  up- 
per respiratory  tract  infection.  It  should  have 
been  a simple  matter  to  present  the  diagnosis, 
discuss  symptomatic  care,  and  answer  ques- 
tions. Rather,  the  focus  seemed  to  be  on  the  fact 
that  this  was  a bad  week  for  her  to  get  ill  due  to 
heavy  workloads  for  the  parents  and  the  result- 
ant need  for  an  immediate  "cure".  It  did  not  help 
our  cause  to  learn  that  this  family  recently 
changed  health  insurance  carriers  and  was 
"forced"  to  leave  their  family  doctor  who  in  the 


past  promptly  called  out  antibiotics  over  the 
phone  when  requested.  The  father  further  added 
that  even  if  this  was  a virus,  he  did  not  want  to 
take  a chance  of  it  developing  into  a more  seri- 
ous infection  and  wished  to  "nip  it  in  the  bud". 
I told  the  father  that  I certainly  empathized  with 
his  medical  displacement  and  appreciated  his 
concern  for  his  child's  welfare.  As  I pulled  up  a 
chair  and  began  my  explanation  of  self-limited 
viral  infections  and  my  justification  for  symp- 
tomatic care,  he  interrupted  me  to  suggest  that  I 
might  be  withholding  a prescriptive  medicine 
in  an  attempt  to  save  money.  He  stated  that  he 
had  read  that  in  this  era  of  managed  care,  im- 
portant life  saving  drugs  and  procedures  were 
often  withheld  for  financial  reasons  and  that  he 
did  not  want  his  child  to  be  a victim  of  this  mis- 
guided program.  At  this  point,  my  medical  stu- 
dent was  aghast.  A lengthy  discussion  followed 
which  set  us  back  for  the  rest  of  the  morning, 
but  was  very  productive  and  revealing. 

After  the  encounter,  the  medical  student 
made  some  poignant  remarks.  She  stated  that 
she  was  aware  of  the  fact  that  the  majority  of 
upper  respiratory  tract  infections  that  pediatri- 


572  J La  State  Med  Soc  VOL  152  November  2000 


cians  encounter  in  healthy  children  are  self-lim- 
ited viral  infections.  She  was  also  aware  of  the 
emergence  of  highly  resistant  strains  of  bacteria 
due  to  the  inappropriate  use  of  antibiotics.  She 
recognized  her  own  strong  desire  to  please  the 
parent  though  she  felt  that  she  would  never  com- 
promise her  scientific  principles.  Yet  she  could 
now  appreciate  how  tempting  and  "efficient"  it 
would  be  to  just  write  a prescription  for  this 
parent  in  the  course  of  a busy  day.  She  wondered 
whether  it  was  our  increasingly  hectic  lifestyles, 
our  drug  oriented  society,  the  media,  managed 
care,  or  general  distrust  of  doctors  that  led  to 
this  confusion  and  conflict.  I,  too,  have  won- 
dered about  this. 

The  emergence  of  multidrug-resistant  bac- 
teria, particularly  Streptococcus  pneumoniae,  is 
well  documented  in  the  medical  literature1'2  as 
well  as  the  lay  press.  The  overzealous  and  often 
inappropriate  use  of  oral  antibiotics  has  contrib- 
uted to  this  crisis.  Many  articles  have  provided 
insight  into  the  underpinnings  of  these  practices 
and  suggestions  on  how  to  reverse  this  trend.3 
A collaborative  set  of  recommendations  by  the 
Centers  for  Disease  Control  and  Prevention,  the 
American  Academy  of  Pediatrics,  and  the 
American  Academy  of  Family  Practice  has  out- 
lined a judicious  approach  to  the  use  of  antimi- 
crobials in  pediatric  respiratory  tract  infections.4 

Despite  these  efforts,  there  appear  to  be  more 
global  issues  that  have  not  been  satisfactorily 
discussed.  The  major  concern  that  has  been 
underemphasized  in  these  discussions  is  the  is- 
sue of  trust  between  the  doctor  and  the  family. 
Having  listened  carefully  to  my  patients,  I have 
determined  several  fundamental  issues  that  in- 
fluence my  credibility  and  the  acceptance  of  my 
medical  advice.  The  above  vignette,  a once 
dreaded  scenario,  is  one  that  I now  welcome  as 
a challenge  and  as  an  opportunity  to  accomplish 
several  goals  in  my  practice.  An  approach  to 
developing  a trusting  relationship  with  parents, 
in  this  era  of  mistrust,  is  contained  in  the  acro- 
nym T.E.A.C.H.. 

"T"  is  for  time.  There  really  is  no  substitute 
for  sitting  down  and  spending  time  with  our  pa- 
tients. Yet  we  are  constantly  trying  to  design  new 


ways  to  mimmize  contact  with  patients.  We  dis- 
tribute checklists  to  obtain  information  and 
handouts  to  explain  management  of  illnesses  in 
order  to  expedite  the  visit.  We  design  new  of- 
fices so  that  a writing  ledge,  which  allows  for 
quick  getaways,  replaces  the  traditional  doctor's 
desk.  We  are  often  substituting  valuable  CME 
opportunities  for  programs  on  how  to  become 
more  efficient  and  cost  effective,  which  often 
translates  into  less  contact  time  with  our  patients. 
The  first  step  in  having  our  patients  accept  our 
recommendations  is  to  take  an  effective  history 
and  to  listen  to  their  concerns.  History  taking  is 
an  art  and  has  therapeutic  value;  if  taken  pa- 
tiently and  compassionately,  it  is  the  first  step  in 
establishing  a trusting  relationship.  This  process 
takes  time. 

"E"  is  for  education.  First,  we,  the  physicians, 
need  to  remain  well  educated.  We  need  to  read 
the  medical  literature,  participate  in  CME,  and 
remain  up  to  date  on  health  and  safety  issues, 
which  affect  our  patients.  In  addition,  we  need 
to  be  effective  teachers.  When  parents  come  to 
our  offices  with  their  sick  child  they  rightfully 
expect  tangible  results.  Many  of  us  erroneously 
assume  that  a prescription  is  all  they  desire.  Af- 
ter all,  doesn't  that  "validate"  their  concern  and 
justify  the  extra  effort  they  took  to  bring  their 
child  in?  We  have  all  seen  the  relief  in  parents' 
faces  when  we  pull  out  our  prescription  pad. 
Isn't  there  some  assurance  in  the  knowledge  that 
at  the  end  of  this  10-day  course  of  medication 
the  child  will  be  totally  back  to  normal?  And  if 
we  do  not  give  our  patients  the  script  won't  they 
just  go  to  another  doctor?  Will  the  family  have 
to  spend  additional  dollars  returning  to  the  of- 
fice if  the  symptoms  worsen?  Studies  refute  these 
assumptions.5  Parents  have  stated  that  they  are 
generally  content  not  to  receive  a prescription  if 
there  has  been  adequate  communication  with 
the  physician.  Educating  parents  will  serve  to 
decrease  the  number  of  visits  through  reducing 
the  perception  that  prescriptions  are  necessary 
for  all  illnesses.  Parents  rightfully  demand  some- 
thing at  the  visit  but  it  is  not  necessarily  a pre- 
scription. We  need  to  patiently  hear  their  con- 
cerns and  carefully  examine  their  child;  then,  we 


J La  State  Med  Soc  VOL  152  November  2000  573 


can  discuss  supportive  care,  alert  the  parents  to 
possible  secondary  infections  that  would  require 
more  aggressive  treatment,  and  review  preven- 
tive strategies.  This  is  also  an  opportunity  for  us 
to  complement  parents  for  their  dedication  to 
their  child's  well  being. 

"A"  is  for  access.  The  father  in  the  above  vi- 
gnette was  negotiating  for  antibiotics  in  part 
because  he  assumed  that  even  though  his  child 
might  have  a viral  illness  at  the  time,  he  antici- 
pated that  it  would  be  very  difficult  to  obtain 
necessary  treatment  by  phone  or  to  make  an- 
other appointment  if  the  condition  worsened.  He 
may  also  have  had  the  belief  that  antibiotics  can 
reliably  prevent  the  progression  of  a mild  illness 
into  a more  serious  one.  Physicians  also  recog- 
nize the  difficulty  in  patient  access  to  their  prac- 
tice during  busy  times  and  this  may  lead  them 
to  injudiciously  prescribe.  It  is  incumbent  on  us 
to  arrange  for  good  access  for  our  patients  and 
to  make  this  part  of  our  therapeutic  discussion 
with  our  families.  If  parents  believe  that  they  will 
be  able  to  access  personalized  medical  care  af- 
ter hours  if  their  child's  condition  worsens,  they 
will  be  far  more  accepting  of  symptomatic  care 
in  the  office. 

"C"  is  for  continuity  of  care.  In  many  com- 
munities, the  trend  has  been  to  establish  large 
group  practices  in  which  patients  frequently  do 
not  see  their  own  doctor.  This  has  resulted  in 
gains  such  as  better  lifestyles  for  physicians, 
longer  hours  of  access,  less  waiting  time  for  ap- 
pointments, and  more  efficient  booking  of  ap- 
pointments. Something  has  been  lost  as  well.6 
All  physicians  appreciate  the  diagnostic  and 
therapeutic  advantage  of  knowing  the  child  and 
the  family.  Parents  are  generally  more  accept- 
ing of  "symptomatic  care"  if  it  is  prescribed  by 
"their"  doctor,  who  knows  "their"  child  and  who 
will  be  there  in  the  future  should  the  child's  con- 
dition worsen. 

"H"  is  for  honesty.  Pediatricians  very  much 
want  to  please  as  part  of  their  provision  of  high 
quality  care.  Not  infrequently,  we  do  not  know 
the  etiology  of  a particular  child's  respiratory 
tract  infection  and  the  potential  benefits  of  anti- 
biotic treatment.  In  these  situations  we  can  iden- 


tify the  "toxic"  child  who  needs  close  monitor- 
ing. If  we  feel  watchful  waiting  is  best,  parents 
generally  will  accept  and  appreciate  our  honest 
confession  that  we  are  not  certain  of  the  diagno- 
sis but  we  will  educate  them  in  clinical  indica- 
tors of  bacterial  infection  and  explain  how  we 
can  be  accessed  if  the  condition  worsens.  (Prac- 
tically speaking,  many  of  us  find  the  presence 
of  a student  or  resident  in  clinic  most  helpful  in 
keeping  us  honest!) 

The  father  in  this  vignette  has  continued  his 
child's  care  with  me  and  we  have  a very  good 
working  relationship  today.  Encounters  such  as 
this  one  have  been  challenging  but  very  instruc- 
tive. Education,  and  the  creation  of  a trusting 
relationship  with  our  professional  families, 
should  be  the  appropriate  prescription  for  the 
21st  century;  these  efforts  will  go  a long  way  in 
reducing  the  trend  towards  inappropriate  anti- 
biotic use.  In  addition,  adherence  to  these  fun- 
damental principles  of  patient  care  should  en- 
hance our  personal  and  professional  satisfaction. 

REFERENCES 

1.  Cohen  ML.  Epidemiology  of  drug  resistance:  im- 
plications for  a post-antimicrobial  era.  Science  1992; 
257:1050-1055. 

2.  Hofman  J,  Cetron  MS,  Farley  MM,  et  al.  The  preva- 
lence of  drug-resistant  Streptococcus  pneumoniae  in 
Atlanta.  NEngl  JMed.  1995;333:481-486. 

3.  Pichichero  ME.  Understanding  antibiotic  overuse 
for  respiratory  tract  infections  in  children.  Pediat- 
rics 1999;104:1384-1388. 

4.  Dowell  SF  (editor).  Principles  of  judicious  use  of 
antimicrobial  agents  for  pediatric  upper  respiratory 
tract  infections.  Pediatrics  1998;  101  (suppl):163-184. 

5.  Mangione-Smith  R,  McGlynn  EA,  Elliott  MN,  et  al. 
The  relationship  between  perceived  parental  expec- 
tations and  pediatrician  antimicrobial  prescribing 
behavior.  Pediatrics  1999;103:711-718. 

6.  Rakatansky  H.  Whither  continuity  of  care?  NEngl 
JMed  1999;341:851-852. 


Dr  Bronfin  is  a clinical  professor  of  pediatrics 
at  Tulane  University  School  of  Medicine, 
and  Chief,  Section  of  General  Pediatrics, 
at  Ochsner  Clinic,  in  New  Orleans,  Louisiana. 


574  J La  State  Med  Soc  VOL  152  November  2000 


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located  in  Baton  Rouge,  Louisiana  (60  miles  from 
New  Orleans)  is  searching  for  BC/BE 
pulmonologist/critical  care  physicians  to  work  as 
intensivist.  Very  unique  job  opportunity.  Position 
offers  1 2 work  shifts  with  a 44  hour  average  work 
week.  Three  and  four  day  alternating  work 
weeks  afford  one  plenty  of  time  off  each  week. 
No  call  when  not  on  duty.  Duties  will  include 
admitting  and  covering  for  intensive  care  units 
and  in-house  pulmonary  patients  at  a single  large 
regional  medical  center.  Position  offers  excellent 
income  ($148,000  salary)  plus  great  benefits. 
Please  fax  CV  to  225.766.8907  or  e-mail  at 
TViator978@aoi.  com. 


Emergency  Medicine  & Primary  Care 
Physicians  Needed 

We  are  seeking  Board  Certified/Board 
Prepared  Emergency  Medicine  and  Primary 
Care  physicians  for  Emergency 
Departments  throughout  Louisiana. 
Positions  offer  competitive  remuneration, 
professional  liability  insurance  procured  on 
your  behalf  and  Independent  Contractor 
status.  All  inquiries  are  confidential.  For 
more  information  contact: 

Traci  Mahlmeister 
PhyAmerica  Physician  Services,  Inc. 
800.476.5986 
919.382.3274  (fax) 
e-mail:  tmahlmei@phyamerica.com 


Medical/Surgical  Equipment  for  Sale. 

New  or  refurbished 

equipment  for  all  health  care  specialties. 
From  exam  rooms  to  operating  rooms,  we 
supply  all  the  equipment  you'll  ever  need, 
new  or  refurbished.  We  are  a Midmark/Ritter 
& Welch  Allyn-authorized  sales  organization. 
Call  for  pricing  and  product  availability. 
Inventory  listings  available  upon  request. 
Contact  our  corporate  sales  office  at: 
800.989.4909 

MESA  Medical,  Inc.,  Chicago,  Illinois. 


Rural  Hospital  located  in  Northeast  Louisiana 
needs  full-time  emergency  room  physicians 
and  part-time  (15  hours  per  week,  including 
call  and  attendance  at  department  meetings 
and  medical  staff  meetings)  medical  directors 
to  supervise  various  clinical  and  quality 
assurance  departments.  Compensation  is 
dependent  upon  experience.  For  more 
details  call  318.435.9411. 


Rural,  solo  family  practice  physician 
in  Covington,  Louisiana  seeks  a 
Family  Practice  or  Internal  Medicine 
physician  to  join  his  practice. 

For  immediate  consideration, 
fax  your  resume  to  504.893.0339. 
All  inquiries  are  kept  confidential. 


J La  State  Med  Soc  VOL  152  November  2000  579 


Business  Opportunities 


Physicians  Needed 

Multi  group  medical  clinic 
in  greater  New  Orleans 
needing  Family  Practitioner  and  Internist 
to  perform  low  stress  jobs  like 
Patient  Evaluations,  Re-Evaluations  and 
Supervision  of  Medical  Assistants. 

Signing  bonus  plus  benefits  and 
opportunity  to  own  up  to  25%  of  practice. 

Fax  CV  to  administrative  office: 
713.278.2084. 

Or  call  administrataive  office: 
713.278  2111 
281.701.7433 
832.978.1178. 


COMPUTER  SLIDE 
PRESENTATIONS 


v 


Generated  On 
35  mm  Slides  • CD  Rom  • Disk 


FOR  SLIDE  PRESENTATIONS  CALL: 

504-782-7917 

or 

E-Mail:  presentslides@aol.com 


Physician's  Office  for  Lease 


Physician's  office  in  Slidell,  fully  equipped  and 
being  used  two  days  a week  as  a second  office; 
vacant  and  available  for  lease  for  the  remaining  2-3 
days  a week. 

For  more  information: 

504.643.0497 


580  J La  State  Med  Soc  VOL  152  November  2000 


Eligible  employed  and  resident  physicians 

The  American  Medical  Association  (AMA)  introduces  Physicians  for 
Responsible  Negotiation  (PRN)  to  bargain  for  you  from  a position  of 
strength  and  to  maintain  AMA  standards  and  ethics  at  all  times. 


Strike  a 

blow  for 

your 

rights 

without 

ever 

going  on 
strike. 


PRN  will: 

• Conduct  a professional 
campaign  to  certify  PRN  as 
your  labor  organization 

• Negotiate  your  contract 
including  working  conditions 
and  patients’  rights 

• Oversee  contract 
administration 

• Subscribe  to  AMA’s 
Code  of  Ethics 


PRN  will  not: 

• Authorize  physician 
strikes  or  withholding 
of  necessary  care 

• Represent  nonphysicians 

• Affiliate  with  traditional 
labor  unions 

For  more  information  about 
PRN  or  other  AMA  physician 
advocacy  initiatives,  call  the 
AMA  at  312  464-4367 


American  Medical  Association 

Physicians  dedicated  to  the  health  of  America 


1.  Publication  Title  J0UE!JAL  q,  jjj.  LOUISIANA 

STATE  MEDICAL  SOCIETY 

2.  Publication  Number 

3.  Filing  Dale 

ol  5 L 1 3 1 - 1 7 ! 0 1 olo 

09-30-00 

4.  Issue  Frequency 

5.  Number  of  Issues  Published  Annually 

6.  Annual  Subscription  Price 

- Sj'o  ■ oo 

Monthly 

12 

LI. 5.-  $35.00 

7.  Complex  Mailing  Address  of  Known  Office  of  Publication  (Not printer)  (Street,  ctiy,  couity,  state,  and  ZtP+4) 
6767  Perkins  Rd. 

Baton  Rouge,  LA  70808 

Contact  Person 

nvi,  3So  CorvVeU 

Telephone 

•2.7-5".  -J03.  3500 

United  Slates  Postal  Service 

Statement  of  Ownership,  Management,  and  Circulation 


8.  Complete  Mailing  Address  of  Headquarters  < 
6767  Perkins  Road 
Baton  Rouge,  LA  70808 


General  Business  Office  of  Publisher  (Not  printer) 


9.  Full  Names  and  Complete  Malting  Addresses  of  Publisher,  Editor,  and  Managing  Editor  (Do  not  leave  blank) 


Publisher  (Name  and  complete  malting  address) 


Louisiana  State  Medical  Society 

6767  Perkins  Rd. 

Baton  Rouge,  LA  70808 


Editor  {Name  and  complete  mailing  address) 


Conway  Magee  , Louisiana  State  Medical  Society 
6767  Perkins  Rd. 

Baton  Rouge,  LA  70808 


Managing  Etfflor  (Name  and  complete  maiting , 


SVAfle'f  j 

bl\§~l  Perk. as 


10.  Owner  (Do  not  leave  blank,  if  the  ptABcadon  Is  owned  by  a corporation,  give  the  name  and  address  of  the  corporation  tovmdaletyfotiowed  by  the 
names  and  addmsses  of  all  stockholders  omtog  or  hokting  1 percent  or  more  of  the  total  amount  of  stock,  ff  not  owned  try  a corporation,  give  the 

names  end  addresses  of  the  In&ridual  owners,  if  owned  by  a partnership  or  other  unincorporated  firm,  rpvetisnamea “ — **- 

each  individual  owner.  If  the  puMcationbpubtished  by  a nonprofit  organization,  give  its  name  and  address.) 


d address  as  weB  as  those  of 


Complete  Mailing  Address 


Lo'u'i; 


iYveA.ctt]  Spot 


fea.-te»A  t L A 1C>%£>& 


11.  Known  Bondholders,  Mortgagees,  and  Other  Security  Holders  Owning  o 
HofcSng  1 Percent  or  More  of  Total  Amount  of  8cnds,  Mortgages,  or 
Other  Securities.  If  none,  check  box  — ■ 


Complete  Mailing  Address 


13,TȤtetU3  (For  ggrnpfs^  hy  rwnpiotit  OT^I^lfQns  aitihorized  to  mail  at  nonprofit  rales)  (Check  one) 

Thejjuipose,  function,  and  nonprofit  status  of  this  organization  and  the  eXSRpl  Status  fcf  federal  ITESTO  to  purpewtl 


13.  Publication  Title  JOURNAL  OF  THE  LOUISIANA  STATE 
MEDICAL  SOCIETY 

14.  Issue  Date  for  Circulation  Data  Below 

June  2000 

15. 

Extent  and  Nature  of  Circulation 

Average  No.  Copies  Each  Issue 
During  Preceding  12  Months 

No.  Copies  of  Single  Issue 
Published  Nearest  to  FTttng  Date 

a.  Total  Number  of  Copies  (Net  press  run) 

6795 

6679 

b.  Paid  and/or 

(1) 

Paid/Requested  Outside-County  Mad  Subscriptions  Staled  on 
Form  3541 . (Include  advertiser^  proof  and  exchange  copies) 

6662 

6554 

(2) 

Paid  in-Ccunty  Subscriptions  (Indude  advertiser's  proof 
and  exchange  copies) 

0 

0 

Circulation 

(3) 

Sales  Through  Dealers  and  Carriers,  Street  Vendors. 

. Counter  Sales,  and  Other  Non-USPS  Paid  Distribution 

0 

0 

(4) 

Other  Classes  Mailed  Through  the  USPS 

0 

0 

Total  Paid  and/or  Requested  Circulation  [Sum  of  15b.  (1).  (2).(3)^nd  k 
(4)1  r 

6662 

6554 

aT=res 
Distribution 
by  Mail 
(Samples, 
oomptiment 
ary  and 
other  free) 

(1) 

Outside-County  as  Slated  on  Form  3541 

0 

0 

0 

0 

0 

0 

(2) 

In-County  as  Staled  on  Form  3541 

(3) 

Other  Classes  Mailed  Through  the  USPS 

Free  Distribution  Outside  the  Mail  (Carriers  or  other  means) 

0 

0 

f.  . 

Total  Free  Distribution  (Sum  of  I5d.  and  15e.)  ^ 

0 

0 

S'  Total  Distribution  (Sion  of  15c.  and  15J)  . ^ 

6662 

6554 

h'  Copies  not  Distributed 

133  : 

125 

Total  (Sum  of  15g.  and  h.)  ^ 

6795 

6679 

1-  Peroent  Paid  and/or  Requeued  Circulation 
(15c.  divided  by  IBg  times  100) 

100% 

100% 

16.  PubScajlion  of  Statement  of  Ownership 

XX30J^rbfication  required^yfiB  be  printed  In  thaiy  6 1>  9i  — ~ZOOQ  issue  of  this  publication. 

□ Publication  not  required- 

Date 

5efterrloer  3Q  ^ 


I certify  that  all  information  furnished  on  this  forflfis  Sue  and  complete  J I understand  that  anyone  who  fuml13hes  false  or  misleading  information  on  this  form 
ir  who  omits  material  or  information  requested  on  the  form  may  be  subject  to  criminal  sanctions  (Inducting  fines  and  imprisonment)  and/or  dv3  sanctions 
(indudng  dvll  penalties). 

Instructions  to  Publishers 

1 . Complete  and  file  one  copy  of  this  form  with  your  postmaster  annually  o 


i or  before  October  1 . Keep  a copy  of  the  completed  form 


In  cases  where  the  stockholder  or  security  holder  Is  a trustee,  indude  In  items  10  and  11  the  name  of  the  person  or  corporation  for 
whom  the  trustee  Is  acting.  Also  indude  the  names  and  addresses  of  individuals  who  are  stockholders  who  own  or  hdd  1 percent 
or  more  of  the  total  amount  of  bonds,  mortgages,  or  other  sacuritles  of  the  publishing  corporation.  In  Item  11 , if  none,  check  the 
box.  Use  blank  sheets  if  more  space  is  required. 

Be  sure  to  furnish  all  drculalion  information  called  for  In  item  15.  Free  circulation  must  be  shown  in  items  15d,  e,  and  f. 

Item  15h.,  Copies  not  Distributed,  must  indude  (1)  newsstand  copies  originally  stated  on  Form  3541 , and  returned  to  the  publish© 
(2)  estimated  returns  from  news  agents,  and  (3),  copies  for  office  use,  leftovers,  spoiled,  and  all  other  copies  not  distributed. 

If  the  publication  had  Periodicals  authorization  as  a general  or  requester  publication,  this  Statement  of  Ownership,  Management, 
and  Circulation  must  be  published;  it  must  be  printed  In  any  issue  in  October  or,  if  the  publication  Is  not  published  during  October, 
the  first  issue  printed  after  October. 

In  item  16.  Indicate  the  date  of  the  ir 
item  17  must  be  skwed. 


9 in  which  this  Statement  of  Ownership  win  be  published. 


J La  State  Med  Soc  VOL  152  November  2000  581 


Advertisers 


American  Medical  Software 

577 

Diagnostic  Imaging 

Inside  Front  Cover,  Outside  Back  Cover 

LAMMICO 

542 

Medical  Protective 

Inside  Back  Cover 

The  Trust  Company 

541 

Tulane  School  of  Public  Health 

576 

582  J La  State  Med  Soc  VOL  1 52  November  2000 


There’s  a simple  way 


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Diagnostic 
Imaging  Services 

Specialists  in  Outpatient  Radiology 
Tenet  Louisiana  HealthSystem 


Metairie  - 3625  Houma  Blvd.  • Marrero  - 925  Avenue  C • Uptown  - 3437  Prytania  St. 


ESTABLISHED  1844 


Vol.  152,  No.  12 


December  2000 


Of  the  Louisiana  State  Medical  Society 


Special  Issue:  Health  Law  and  Biomedical  Ethics 


HS/HSL 

UNIVERSITY  OF  MARYLAND 
BALTIMORE 


Intellectual  Property  Law  and  Genetic  Health  Care 
Human  Embryonic  Stem  Cell  Research:  Implications  from  an  Ethical  and  Legal  Standpoint 

In  Vitro  Fertilization:  A Right  or  Privilege? 

Domestic  Violence  in  Medical  Practice:  A New  Approach  for  Louisiana  Physicians 
Physician  Unions  - An  Ethical  and  Legal  Issue  in  Health  Care  Delivery 
Cardiopulmonary  Resuscitation  and  Medical  Ethics 
ECG  of  the  Month:  Not  To  Be  Sneezed  At 
Otolaryngology/Head  and  Neck  Surgery  Report:  Caustic  Ingestion 

Radiology  Case  of  the  Month:  Constipation  Since  Birth  J§ 

i*  4 

History  of  Medicine:  University  of  Louisiana  ' , 


powerful  gradients  currently  approved  by  the 
FDA,  peripheral  MR  Angiography  studies  of  the 
lower  extremities  are  greatly  improved  and  can 
serve  as  an  alternative  to  invasive  conventional 
angiography.  Medicare  now  provides 
coverage  and  has  approved  MRA 
as  an  appropriate  test  in  determining 
the  extent  of  peripheral  vascular 
disease  in  the  lower  extremities. 
Additionally,  MRA  has  been  shown  to  find 
occult  flow  in  blood  vessels  where  it  was  not 
apparent  on  conventional  angiography. 

MRA  is  a non-invasive  test  and 


requires 

no  iodinated  contrast,  which  reduces  the  risk 
of  complications  and  allergic  reactions.  So,  if 
you  have  a patient  who  would  benefit  from  an 
MRA  study  of  the  lower  extremities,  call  DIS  at 
883-5999  to  schedule  an  appointment  today. 

■ Diagnostic 
Imaging  Services 

Specialists  in  Outpatient  Radiology 

Tenet  Louisiana  HealthSystem 

Uptown  3437  Prytania  St.*  Metairie  3625  Houma  Blvd. 

Marrero  925  Avenue  C 


Practice  Accredited  by  the  American  College  of  Radiology 


NOW  OPEN  - AVENUE  C / MARRERO  LOCATION 


Editor 

CONWAY  S.  MAGEE,  MD 


Chief  Executive  Officer 

DAVE  TARVER 

General  Manager 

CATHY  LEWIS 

Managing  Editor 

ANNE  SHIRLEY 

Advertising  Coordinator 

MELISSA  CANTRELL 


BOARD  OF  TRUSTEES 
Chairman,  CONWAY  S.  MAGEE,  MD 
K.  BARTON  FARRIS,  MD 
ANTHONY  P.  BLALOCK,  MD 
FRED  A.  LOPEZ,  MD 
Ex  officio,  DUDLEY  M.  STEWART  JR,  MD 


Special  issue:  Health  Law  and  Biomedical  Ethics 


EDITORIAL  BOARD 
A.  JOANNE  GATES,  MD 
RODNEY  C.  JUNG,  MD 
PATRICK  W.  PEAVY,  MD 
TRENTON  L.  JAMES  II,  MD 
JACK  P.  STRONG,  MD 

CLAY  A.  WAGGENSPACK  JR,  MD 
WINSTON  H.  WEESE,  MD 

LSMS  BOARD  OF  GOVERNORS 
DUDLEY  M.  STEWART  JR,  MD 
K.  BARTON  FARRIS,  MD 
KEITH  F.  DESONIER,  MD 
C.  CLINTON  LEWIS,  MD 
RUSSELL  C.  KLEIN,  MD 
CAROL  BAYER,  MD 
WALLACE  H.  DUNLAP,  MD 
CHARLES  D.  BELLEAU,  MD 
BROOKE  S.  PARISH,  MD 
VINCENT  A.  CULOTTA  JR,  MD 
RICHARD  J.  PADDOCK,  MD 
BARRY  G LANDRY,  MD 
WILLIAM  T.  HALL,  MD 
JOSEPH  BUSBY  JR,  MD 
DAVID  G.  FOURRIER,  MD 
R.  MARK  WILLIAMS,  MD 
MARTIN  B.  TANNER,  MD 
MARTIN  J.  DUCOTE  JR,  MD 
MARCUS  L.  PITTMAN  III,  MD 
LAURA  BRESNAHAN  ROBERTS 

ESTABLISHED  1844.  Owned  and  edited  by  the 
Journal  of  the 
Louisiana  State  Medical  Society,  Inc., 
6767  Perkins  Road,  Baton  Rouge,  LA  70808; 
phone:  225.763.2310;  fax:  225.763.2332. 
e-mail:  publicaffairs@lsms.org 
Internet:  www.lsms.org 

Copyright  2000  by  the  Journal  of  the 
Louisiana  State  Medical  Society,  Inc. 

Subscription  price  is  $35  per  year  in  advance, 
postage  paid  for  the  United  States; 
$50  per  year  for  all  foreign  countries 
belonging  to  the  Postal  Union. 

Advertising:  Contact  the  Department  of  Public  Affairs. 
6767  Perkins  Road,  Baton  Rouge,  LA  70808; 

225.763.2310. 

Postmaster:  Send  address  changes  to 
6767  Perkins  Road,  Baton  Rouge,  LA  70808. 

The  Journal  of  the  Louisiana  State  Medical  Society 

(ISSN  0024-6921)  is  published  monthly 

at  6767  Perkins  Road,  Louisiana  State  Medical  Society, 
Baton  Rouge,  LA  70808. 
Periodical  postage  paid  at  Baton  Rouge,  LA 
and  additional  mailing  offices. 

Articles  and  Advertisements  published  in  the  Journal 
are  for  the  interests  of  its  readers  and  do  not 
necessarily  represent  the  official  position  or 
endorsement  of  the  Journal  of  the  Louisiana 
State  Medical  Society,  Inc.  or  the 
Louisiana  State  Medical  Society. 

The  Journal  reserves  the  right  to  make  the  final 
decision  on  all  content  and  advertisements. 


Joanne  Cain  Marier,  JD 
Nathan  J.  Markward,  MPH 
Danielle  M.  Trepagnier,  BA 

Brooke  Lambard  Kyle,  MD 
Nancy  Kang,  BA 

Benjamin  K.  Canales,  BS 

Lawrence  Montelibano,  BA 


Articles 

605  Health  Law  and  Biomedical  Ethics: 

An  Introduction 

607  Intellectual  Property  Law  and 

Genetic  Health  Care 

616  Human  Embryonic  Stem  Cell  Research: 

Implications  from  an  Ethical  and  Legal 
Standpoint 

625  In  Vitro  Fertilization:  A Right  or  A Privilege? 

630  Domestic  Violence  in  Medical  Practice: 

A New  Approach  for  Louisiana  Physicians 

635  Physician  Unions —An  Ethical  and  Legal  Issue 
in  Health  Care  Delivery 

642  Cardiopulmonary  Resuscitation  and 

Medical  Ethics 


UEPART 

MtNTS — - 

584 

INFORMATION  FOR  AUTHORS 

Jorge  1.  Martinez-Lopez, 

MD 

587 

ECG  OF  THE  MONTH 
Not  To  Be  Sneezed  At 

Stephen  B.  Schaffer, 
A.  Foster  Hebert, 

MD 

MD 

590 

OTOLARYNGOLOGY/HEAD  & NECK 
SURGERY  REPORT 
Caustic  Ingestion 

Harold  R.  Neitzschman, 
Akshay  S.  Gupta, 

MD 

MD 

597 

RADIOLOGY  CASE  OF  THE  MONTH 
Constipation  Since  Birth 

Gustovo  A.  Colon, 

MD 

600 

HISTORY  OF  MEDICINE 
University  of  Louisiana 

650 

CALENDAR 

652 

CLASSIFIED  ADVERTISING 

655 

AUTHOR  INDEX 

658 

SUBJECT  INDEX 

Eugene  New 
New  Orleans 


J La  State  Med  Soc  VOL  152  December  2000 


583 


Information  for  Authors 


The  Journal  is  published  for  the  benefit  of  the  members  of  the  Louisiana  State 
Medical  Society.  Manuscripts  should  be  of  interest  to  a broad  spectrum  of  phy- 
sicians and  designed  to  provide  practical  information  on  the  current  status 
and  the  progress  and  changes  in  the  field  of  clinical  medicine.  The  articles 
published  are  primarily  original  scientific  studies  but  may  include  societal, 
socioeconomic,  or  medicolegal  topics. 

Review  Process 

Each  submission  is  reviewed  by  the  editor  and  is  subject  to  peer  review  by  one 
of  the  editorial  consultants.  Manuscripts  are  also  subject  to  editorial  revision 
and  to  such  modification  as  to  bring  them  into  conformity  with  Journal  style. 
The  final  decision  to  accept  or  revise  falls  to  the  editor. 

Preparation  of  the  Typescript 

Allow  margins  of  at  least  1 inch  on  all  sides;  avoid  end-of-line  hyphens;  num- 
ber all  pages,  starting  with  the  title  page;  begin  each  major  part  of  the  manu- 
script on  a new  page;  double-space  all  parts  of  the  manuscript.  Submit  the 
manuscript  in  triplicate. 

Computer  Disk 

When  the  manuscript  has  been  accepted,  the  author  will  be  asked  to  submit  a 
3.5"  diskette  with  language  exactly  matching  that  of  the  accepted  version. 

Style  Conventions 

Units  of  measure.  Use  conventional  units.  If  essential,  SI  units  may  be 
added  in  parentheses  immediately  following  the  conventional  expression. 

Drug  names.  Use  the  generic  form.  If  the  proprietary  name  is  relevant  to 
the  study,  it  may  be  added  in  parentheses  immediately  following  the  first  men- 
tion of  the  generic  name.  A generic  name  is  lowercased;  a proprietary  name  is 
capitalized. 

Citing  a reference  entry.  Use  superior  arabic  numerals  placed  at  the  logi- 
cal site  in  the  sentence;  insert  immediately  after  a word  or  mark  of  punctua- 
tion; set  close.  Cite  in  the  main  text,  in  tables,  and  in  the  legends  for  illustra- 
tions; do  not  cite  in  the  abstract. 

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1.  Brush  JE  Jr,  Cannon  RO  III,  Schenke  WH,  et  al.  Angina  due  to  coro- 
nary microvascular  disease  in  hypertensive  patients  without  left  ven- 
tricular hypertrophy.  NEngl  JMed  1988;319:1302-1307. 

2.  Hajdu  SI.  Pathology  of  Soft  Tissue  Tumors.  Philadelphia,  Pa:  Lea  & 
Febiger;  1979:60-83. 

3.  Robinson  BH.  Lactic  acidemia.  In:  Scriver  CR,  Beaudet  AL,  Sly  WS, 
et  al  (editors).  The  Metabolic  Basis  of  Inherited  Disease,  6th  edition. 
New  York:  McGraw-Hill;  1989:869-888. 

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586  J La  State  Med  Soc  VOL  1 52  December  2000 


ECG  of  the  Month 


Not  To  Be  Sneezed  At 

Jorge  I.  Martinez-Lopez,  MD 


The  rhythm  strip  shown  below,  limb  lead  II,  is  only  a portion  of  a lengthy  recording  that  lay 
dormant  in  my  office  for  the  past  5 years;  it  was  found  behind  a stack  of  papers.  If  there 
ever  was  any  pertinent  clinical  information,  it  is  nowhere  to  be  found. 


What  is  your  diagnosis? 
Elucidation  begins  on  page  588 


J La  State  Med  Soc  VOL  152  December  2000  587 


ECG  of  the  Month 
Presentation  is  on  page  587. 

DIAGNOSIS  - Sinus  node  dysfunction 

Even  though  vital  information  is  lacking,  it 
should  not  be  a deterrent  to  examination  of  the 
tracing,  with  respect  to  diagnosis,  and  specula- 
tion of  its  possible  causes  and  management. 

One  finding  is  immediately  apparent:  P 
waves  are  few  and  far  between.  The  rhythm  is 
somewhat  irregular,  with  shorter  cycles  occa- 
sionally flanked  by  longer  cycle  lengths.  Every 
QRS  is  preceded  by  a sinus  P wave  (1:1  AV  con- 
duction) and  every  P wave  is  associated  with  a 
normal  PR  interval  (normal  AV  conduction).  In- 
traventricular conduction  of  the  sinus  impulses 
is  also  normal  (narrow  QRS  complexes).  The  ST 
segment  is  isoelectric,  the  T waves  upright,  and 
the  QT  interval  of  normal  duration. 

Overall,  the  basic  rhythm  appears  to  be  si- 
nus bradycardia,  not  consistently  regular,  but 
with  some  irregularity.  Most  impressive,  of 
course,  are  the  long  pauses  recorded  in  the  top, 
third,  and  fourth  rows.  When  these  pauses  oc- 
cur, no  clear-cut  electrical  activity — either  atrial 
or  ventricular — is  recorded. 

Several  conditions  may  be  responsible  for 
such  a tracing.  Sinus  arrhythmia  is  unlikely  to 
be  an  explanation  because  there  is  no  apparent 
waxing  and  waning  of  the  rhythm,  as  would  be 
expected  in  the  presence  of  respiratory  (phasic) 
sinus  arrhythmia.  It  is  also  unlikely  that  the  long 
pauses  are  caused  by  non-conducted  atrial  pre- 
mature impulses,  because  there  is  no  obvious 
deformity  on  the  T waves  that  usher  in  such 
pauses,  when  these  T waves  are  compared  with 
other  T waves  not  followed  by  a pause. 

Together,  the  ECG  findings  strongly  suggest 
the  presence  of  sinus  node  dysfunction  (SND)  or 
sick  sinus  syndrome.  Neither  term  is  a specific 
clinical  diagnosis.  Instead,  both  represent  a col- 
lective term  used  to  describe  the  existence  of  a 
wide  spectrum  of  arrhythmias  due  to  malfunc- 
tion of  the  sinus  node.  Such  arrhythmias  may 
be  acute  or  chronic,  functional  or  organic,  re- 


versible or  irreversible,  and  primary  or  second- 
ary. Recall  that  the  normal  function  of  the  sinus 
node  can  be  altered  by  a variety  of  extrinsic  and 
intrinsic  factors,  and  by  the  interaction  of  these 
two  major  determinants. 

The  abrupt  and  intermittent  appearance  of 
unexpected  long  pauses  found  in  the  tracing  sug- 
gests a disturbance  either  in  the  generation  of 
sinus  impulses  (impulse  formation)  or  in  the  con- 
duction of  impulses  from  the  sinus  node  to  the 
atrial  musculature  (sinus  exit  block).  It  is  not  al- 
ways possible  to  differentiate  between  these  two 
mechanisms  because  both  situations  share  one 
thing  in  common:  atrial  depolarization  is  absent 
when  sinus  impulses  fail  to  reach  the  atria,  and 
no  P wave  is  inscribed. 

The  commoner  of  the  two  mechanisms  is  si- 
nus exit  block  (SEB).  The  classification  used  to 
describe  SEB  is  analogous  to  that  used  for  AV 
block.  The  diagnosis  of  first-  and  third-degree  SEB 
cannot  be  made  from  the  surface  ECG,  but  sec- 
ond-degree SEB  can  be  diagnosed  on  the  surface 
ECG.  In  general,  second-degree  SEB  is  present 
when  some,  but  not  all,  of  the  sinus  impulses 
are  prevented  from  exiting  the  sinus  node;  vari- 
able ratios  of  SEB  may  lead  to  "group  beating" 
on  the  ECG.  Second-degree  SEB  is  of  two  types. 
Type  I (Wenckebach)  SEB  manifests  with  P-P  in- 
tervals that  gradually  shorten  until  one  electri- 
cal impulse  fails  to  exit  the  sinus  node.  In  type  II 
SEB,  recorded  P-P  intervals  remain  similar  or 
identical  during  sinus  rhythm,  and  the  tracing 
shows  intermittent  pauses  that  are  "exact"  mul- 
tiples of  the  basic  P-P  intervals.  In  both  types  of 
SEB,  the  blocked  sinus  impulses  will  be  mani- 
fested by  the  absence  of  P waves. 

Review  of  the  tracing  shows  that  the  long  si- 
nus pauses  range  from  a "short"  one  of  3.6  sec- 
onds to  a "long"  one  of  5.4  seconds.  However, 
none  of  these  pauses  corresponds  to  a multiple 
of  the  basic  sinus  rhythm.  This  finding  suggests, 
but  does  not  prove,  that  the  pauses  may  be  due 
to  intermittent  sinus  arrest,  rather  than  to  SEB. 
Failure  to  generate  one  or  more  sinus  impulses, 
a rare  clinical  phenomenon  compared  to  SEB,  is 
manifested  by  the  transient  absence  of  P waves 
that  may  last  longer  than  2 seconds.  The  pause 


588  J La  State  Med  Soc  VOL  1 52  December  2000 


is  referred  to  as  a sinus  pause  or  arrest.  P-P  in- 
tervals are  not  multiples  of  the  basic  sinus  cycles, 
but  are  random  in  duration.  The  abnormal  sup- 
pression of  the  sinus  node  is  not  uncommonly 
due  to  the  cardiotoxic  effects  of  a drug.  In  such  a 
setting,  withdrawal  of  the  drug(s)  likely  to  play 
a role  in  the  SND  is  usually  sufficient  therapy. 
In  obstinate  cases,  a temporary  pacemaker  may 
be  necessary  until  the  suppressive  effects  of  the 
offending  agent(s)  dissipate. 

There  is  another  disturbing  finding  in  the 
tracing.  Whether  the  long  pauses  are  due  to  ei- 
ther SEB  or  sinus  arrest,  it  is  not  unusual  for  an 
escape  rhythm  to  emerge  to  rescue  the  patient 
from  the  jaws  of  cardiac  arrest.  Most  often,  the 
intrinsic  escape  pacemaker  is  located  above  the 
bundle  of  His;  less  often,  it  is  in  the  ventricular 
myocardium.  However,  in  patients  with  SND 
and  intact  AV  conduction,  such  as  this  patient, 
escape  rhythms  may  not  be  stable  or  depend- 
able. Therefore,  the  failure  of  a subsidiary  pace- 
maker to  escape  during  the  long  pauses  found 
in  this  tracing  may  be  an  indication  that  its  func- 
tion and  role  as  a rescue  mechanism  are  also  se- 
riously impaired  or  depressed.  Symptoms  re- 
lated to  cerebral  hypoperfusion  in  patients  with 
SND  are  most  often  related  to  the  marked  delay 
or  the  absence  of  escape  impulses  that  result  in 
a long  cardiac  asystole. 

The  sum  total  of  this  tracing — even  without 
the  benefit  of  clinical  data — is  that  it  is  "not  to 
be  sneezed  at".  It  is  a sinus  condition  that  re- 
quires immediate  attention  and  aggressive  man- 
agement, including  the  possible  implantation  of 
a permanent  cardiac  pacemaker. 

The  first  year  of  tracings  for  this  new  cen- 
tury has  ended.  As  we  go  into  the  year  2001,  may 
you  and  yours  have  a Happy  Holiday  Season. 

ACKNOWLEDGMENT 

My  most  sincere  thanks  and  appreciation  go  to 
Mrs  Denise  Renteria,  my  secretary,  who  played 
a major  role  in  the  preparation  of  manuscripts 
for  the  year  2000. 


Dr  Martinez-Lopez  is  a specialist  in  cardiovascular 
diseases  affiliated  with  the  Cardiology  Service,  Department 
of  Medicine,  Texas  Tech  University  Health  Sciences  Center 
and  Thomason  General  Hospital  in  El  Paso,  Texas. 


J La  State  Med  Soc  VOL  152  December  2000  589 


Otolaryngology/ 




Caustic  Ingestion 

Stephen  B.  Schaffer,  MD  and  A.  Foster  Hebert,  MD 


Caustic  and  corrosive  injury  of  the  upper  gastrointestinal  tract  can  lead  to  significant  morbid- 
ity and  mortality  with  the  development  of  upper  gastrointestinal  stricture  or  perforation. 
Household  products  containing  alkalis,  acids,  and  detergents  are  responsible  for  most  inju- 
ries, with  each  having  varying  histological  injury  patterns  and  anatomic  distribution.  Early 
signs  and  symptoms  after  caustic  ingestion  are  not  consistent  with  the  extent  of  damage,  and 
endoscopy  is  the  only  reliable  method  to  assess  injury.  Medical  and  surgical  treatments  are 
controversial  and  include  steroids,  antibiotics,  esophageal  dilation,  stenting,  and  surgical  re- 
construction and  are  centered  around  prevention  of  esophageal  strictures.  Early  diagnosis 
and  prompt  and  aggressive  treatment  can  improve  long-term  outcomes  in  these  patients. 


Chemical  ingestion  is  a therapeutic  prob- 
lem faced  regularly  by  the  clinician,  with 
continuing  controversy  concerning  the 
proper  management  of  these  patients.  This  ar- 
ticle summarizes  the  most  current  approaches 
to  the  pathophysiology,  diagnosis,  and  treatment 
of  chemical  upper  gastrointestinal  injury. 

EPIDEMIOLOGY 

Approximately  5,000-15,000  cases  of  accidental 
and  intentional  chemical  ingestion  are  estimated 


to  occur  in  the  United  States  every  year.1  Most 
recent  literature  estimates  that  50%  to  80%  of 
cases  are  found  in  the  pediatric  population,  with 
a male  to  female  distribution  of  2:1. 2 The  distri- 
bution of  cases  by  age  is  bimodal,  with  a large 
representation  of  predominantly  accidental 
ingestions  falling  between  1 and  5 years  of  age. 
Ingestion  may  occasionally  represent  a form  of 
child  abuse.  The  other  peak  in  incidence  occurs 
in  an  age  group  of  21  years  of  age  and  older, 
with  a majority  representing  intentional  inges- 


590  J La  State  Med  Soc  VOL  1 52  December  2000 


tion.  In  1980,  between  510  and  850  alkaline  bat- 
teries were  ingested  in  the  United  States,  mostly 
by  children.1 

Many  factors  have  been  responsible  for  ma- 
jor changes  in  the  epidemiology  of  caustic  in- 
gestion. Legislation  such  as  the  Safe  Packaging 
Act,  in  force  since  1970,  has  been  concerned  with 
making  acid  and  alkali  products  safer  for  house- 
hold use.  Laws  have  emphasized  clear  labeling 
with  danger  or  poison  postings,  have  made 
bottles  more  difficult  to  open,  and  have  required 
that  products  with  concentrations  of  alkali  in 
excess  of  10%  be  childproof.  The  number  of  re- 
ported cases  dropped  by  31%  between  1970  and 
1982,  with  a 35%  decrease  in  the  number  of  hos- 
pitalizations.3 

Another  epidemiologically  relevant  factor 
has  been  the  change  in  the  nature  and  anatomi- 
cal distribution  of  caustic  injury  in  the  past  cen- 
tury. This  change  has  followed  the  manufactur- 
ing trends  of  retail  home  lye  products  from  solid 
to  mostly  liquid  forms.  Liquids  lead  to  damage 
of  a large  amount  of  mucosa  from  the  oral  cav- 
ity to  the  duodenum  in  a swallow,  whereas  a 
solid  lye  product  is  more  likely  to  lead  to  a lo- 
calized area  of  oropharyngeal  injury. 

PATHOPHYSIOLOGY 

The  severity  of  chemical  injury  is  related  to  the 
concentration,  duration  of  contact,  and  nature 
of  the  offending  substance. 

The  most  common  classification  of  burns  is 
listed  in  Table  l:4 


Table  1 : Classification  of  esophageal  burns 

Grade  I 

Superficial  mucosal  hyperemia, 
mucosal  edema,  and  superficial 
sloughing 

Grade  II 

Transmucosal  ulceration,  with 
involvement  of  muscular  layers  of  the 
esophagus  with  exudate  and  edema 

Grade  III 

Transmural  ulceration  with  erosion 
into  peri-esophageal  tissues  including 
the  mediastinum  and  pleural  and 
peritoneal  cavities 

The  most  common  agents  responsible  for 
chemical  injuries  fall  into  three  categories,  each 
with  distinct  histologic  features  and  distribution. 

Alkali  (caustic)  agents  in  the  liquid  form  are 
almost  tasteless  and  are  more  dense  than  water, 
resulting  in  more  distal  injuries.  Alkalis  cause 
saponification  of  fat  and  denaturing  of  proteins, 
blood  vessel  thrombosis,  and  liquifaction  necro- 
sis. Early  disintegration  of  the  mucosa  and  deep 
tissue  penetration  can  progress  for  over  2-3  days 
after  ingestion,5  with  the  esophageal  wall  being 
weakest  7-21  days  after  the  injury.  The  body  pro- 
motes healing  by  laying  down  collagen,  with  the 
first  strictures  apparent  at  approximately  3 
weeks.  However,  strictures  have  been  shown  to 
develop  months  to  years  after  injury. 

Approximately  30%  of  children  ingesting 
alkali  have  esophageal  burns,  with  56%  having 
Grade  II-III  burns  that  go  on  to  develop  stric- 
tures.6 Burns  are  most  likely  to  occur  in  the 
esophagus  at  regions  of  anatomic  narrowing, 
including  the  cricopharyngeus,  the  aortic  arch, 
the  left  main  stem  bronchus,  and  the  diaphrag- 
matic hiatus.  The  stomach  is  spared  in  80%  of 
cases  of  alkali  ingestion.  Critical  pH  to  produce 
ulcers  and  strictures  in  animals  is  12.5.  Contact 
for  less  than  1 second  with  30%  liquid  NaOH 
can  produce  transmural  necrosis  in  animals.6 
Liquid-Plumr  (8%  potassium  hydroxide)  can 
cause  complete  liquifaction  of  the  mucosa  of  a 
cat  after  a 1 second  exposure,  with  edema  and 
inflammation  of  the  muscularis  mucosa  and  sub- 
mucosal adventitia.4  The  decrease  in  concentra- 
tions of  lye  in  retail  products  (to  under  10%)  has 
likely  had  little  effect  on  the  severity  of  esoph- 
ageal burns  from  alkali. 

Disc  "button"  batteries  are  responsible  for  a 
unique  type  of  esophageal  burn.  The  majority 
of  batteries  are  from  hearing  aids,  and  in  40%  of 
children  are  from  their  own.7  An  alkaline  bat- 
tery in  saline  can  reach  a pH  of  12,  which  leads 
to  the  development  of  an  electrochemical  cur- 
rent across  the  battery's  seal  and  can  cause  cor- 
rosion and  leakage  of  the  battery  contents.  Most 
of  the  batteries  transverse  the  gastrointestinal 
tract  without  harm.  A battery  that  lodges  in  the 
esophagus,  however,  can  cause  mucosal  dam- 


J La  State  Med  Soc  VOL  152  December  2000  591 


age  in  1 hour  and  perforation  in  8 to  12  hours.8 

Detergents  containing  sodium  tripolyphos- 
phate or  sodium  carbonate,  including  many 
denture  cleaning  products  and  household  de- 
tergents, should  be  considered  caustic.  These 
agents  cause  mild  mucosal  ulcerations  and 
rarely  cause  strictures,  but  endoscopy  is  recom- 
mended.6 

Acid  (corrosive)  agents  are  responsible  for 
approximately  15%  of  caustic  ingestions.  They 
cause  a coagulative  necrosis  of  the  mucosa,  in 
which  the  coagulum  serves  as  a protective  bar- 
rier, limiting  deeper  penetration  into  the  mus- 
cular layers  of  the  esophagus  during  the  short 
transit  time  of  a swallow.  Esophageal  burns  oc- 
cur in  only  6%  to  20%  of  cases  with  acid 
ingestions,6  whereas  there  is  a higher  incidence 
of  gastric  perforation  and  stricture.  When  burns 
do  occur,  they  are  manifested  by  a sloughing  of 
the  mucosa  of  a large  surface  area  of  the  stom- 
ach and  esophagus.  At  most  risk  is  the  antrum 
of  the  stomach  where  the  swallowed  material 
tends  to  pool.  In  the  absence  of  a buffer,  this  col- 
lection can  induce  spasm  of  the  pylorus  and  pre- 
vent gastric  emptying.  The  highly  irritative  and 
unpleasant  taste  of  acid  agents,  in  contrast  to 
alkali,  often  leading  to  choking  and  gagging 
episodes.  In  this  way,  acid  is  brought  in  contact 
with  the  glottic  structures,  and  chemical  epi- 
glottitis with  airway  compromise  can  result.4 

Bleaches  have  an  essentially  neutral  pH  and 
are  classified  as  esophageal  irritants,  although 
acute  laryngeal  edema  could  pose  an  airway 
problem.  They  do  not  cause  significant  long- 
term esophageal  injury,  and  extensive  workup 
is  not  indicated. 

CLINICAL  PRESENTATION 

The  majority  of  cases  occur  in  the  pediatric  popu- 
lation in  unsupervised  settings,  and  a history  can 
be  erroneous.  Often  the  offending  agent  is  in  an 
unmarked  container.  Any  information  available 
regarding  the  nature  of  the  ingested  substance 
is  helpful.  Local  Poison  Control  Centers  have 
extensive  databases  which  include  the  chemical 
derivation  and  treatment  recommendations  for 


Table  2:  Common  household  corrosives 

Alkali(caustic) 

NaOH,  KOH  (oven  cleaners,  liquid 
agents  liquid  drain  cleaners,  Clinitest 
tablets,  denture  cleaners,  hair  relax- 
ants),  ammonia,  some  electric 
dishwasher  soaps 

Acid  (corrosive) 
agents 

Sulfuric  acid,  hydrochloric  acid 
(toilet  bowl  cleaners) 

Bleaches 

Chloride  bleaches,  peroxide,  mil- 
dew removers 

most  retail  products  and  can  be  helpful  in  man- 
agement of  these  patients. 

Patients  may  present  with  obvious  burns  of 
the  lips,  mouth  and  oropharynx,  often  with  gray- 
black  pseudomembranes  and  eschar.  Patients 
with  significant  laryngeal  or  epiglottic  edema 
can  develop  hoarseness,  aphonia,  stridor,  or 
dyspnea.  Upper  airway  lesions  have  been  found 
in  a significant  number  of  cases  of  severe  esoph- 
agitis in  children.  Patients  with  significant  vom- 
iting or  drooling  should  be  suspected  of  having 
atony  or  narrowing  of  the  esophagus.  Symptoms 
of  caustic  ingestion  can  also  include  dysphagia, 
odynophagia,  recurrent  emesis,  or  hematemesis. 
Severe  burns  or  perforations  can  sometimes  be 
manifest  by  substernal  or  back  pain,  abdominal 
tenderness,  or  peritoneal  signs.  It  is  important 
to  remember,  however,  that  from  to  8%  to  20% 
of  patients  with  significant  esophageal  or  stom- 
ach burns  can  present  with  no  oral  lesions  or 
other  obvious  signs  or  symptoms.9  Laboratory 
tests  have  not  been  found  to  be  helpful  in  initial 
management,  except  to  treat  complications  such 
as  hemorrhage,  shock,  or  renal  failure. 

Numerous  studies  have  attempted  to  corre- 
late signs  or  symptoms  with  the  severity  or  ex- 
tent of  caustic  ingestion  injuries,  but  no  sensi- 
tive indicators  have  been  suggested.  Caustic  in- 
juries, then,  are  not  a clinical  diagnosis,  and  a 
high  level  of  suspicion  must  be  maintained  to 
prevent  missing  a potentially  morbid  lesion.  Lor 
these  reasons,  endoscopy  is  an  essential  part  of 
the  evaluation. 


592  J La  State  Med  Soc  VOL  1 52  December  2000 


ENDOSCOPY 

Some  early  reports  of  the  use  of  rigid  endoscopy 
with  caustic  ingestion  patients  revealed  an 
alarmingly  high  rate  of  complications,  prima- 
rily esophageal  perforations.4  The  increasing  use 
of  flexible  endoscopy  has  shown  a much  better 
safety  record  and  is  now  the  gold  standard  for 
most  of  these  cases.  Flexible  endoscopy  also  al- 
lows visualization  of  the  stomach  and  the  first 
part  of  the  duodenum,  where  these  burns  can 
often  occur.  Rigid  endoscopy  is  indicated  for 
assistance  in  placing  a feeding  nasogastric  tube 
or  if  airway  control  is  an  issue.10 

The  timing  of  endoscopy  is  controversial. 
Some  authors  suggest  that  endoscopy  done  less 
than  24  hours  after  injury  does  not  allow  enough 
time  for  complete  demarcation  of  the  burn  and 
subsequent  underestimation  of  injury,4  although 
early  endoscopy  has  not  been  found  to  be  a nega- 
tive factor  in  some  studies.11  Advantages  to  early 
endoscopy  include  early  institution  of  treatment 
or  discharge,  if  the  patient  has  an  unrevealing 
examination.  Endoscopy  done  after  48  hours  is 
considered  high  risk  because  of  the  progressive 
weakening  of  the  esophageal  wall.  Endoscopy 
undertaken  in  the  24  to  48  hour  post-injury  pe- 
riod is  most  widely  accepted. 

Some  authors  have  suggested  that  an  endo- 
scope should  not  be  advanced  beyond  the  area 
of  a known  burn  so  as  not  to  induce  a mucosal 
tear  or  perforation.4  However,  recent  series  us- 
ing flexible  endoscopes  suggest  no  need  to  stop 
at  a burned  area.17  Because  bums  to  the  orophar- 
ynx do  not  correlate  with  burns  to  the  esopha- 
gus or  stomach,  and  because  esophageal  burns 
do  not  correlate  with  burns  to  the  stomach  and 
duodenum,  most  contemporary  authors  recom- 
mend complete  endoscopy,  even  beyond  known 
lesions.4 

IMAGING 

Barium  esophagram  (BE)  is  a sub-optimal  study 
in  the  immediate  post-ingestion  period,  as  evi- 
denced by  reports  of  high  false-negative  rates.6 
Consideration  should  only  be  given  to  this  study 
in  cases  of  suspected  perforation  or  in  the  case 


of  a delayed  presentation  (greater  than  48  hours) 
when  endoscopy  can  no  longer  be  performed 
safely.  When  present,  findings  include  diffusely 
blurred  margins  secondary  to  ulceration,  evi- 
dence of  sloughing,  and  pseudomembranes.  In- 
tramural collections  of  contrast  can  be  found 
with  dissection  of  the  esophageal  wall,  and  deep 
necrotic  ulcers  are  often  manifest  by  linear 
streaks  and  plaque-like  collections  of  contrast. 
Gaseous  dilatation  of  the  esophagus  and  intralu- 
minal retention  of  contrast  can  suggest  impend- 
ing perforation. 

The  primary  role  of  the  barium  esophagram 
is  in  long-term  follow-up  of  patients,  where  signs 
of  stenosis  and  aperistalsis  are  accurately  dis- 
played. The  initial  study  should  occur  at  4 
weeks12  and  repeated  as  necessary  with  new 
onset  dysphagia,  even  decades  after  the  incit- 
ing event.  It  is  important  to  remember  that  stric- 
tures and  esophageal  carcinoma  can  occur  as 
long  as  10  to  25  years  after  injury. 

TREATMENT 

Immediate  management  of  caustic  injury  re- 
quires appropriate  airway  management  in  the 
setting  of  hoarseness,  stridor,  or  dysphagia.  Typi- 
cal treatments  such  as  emetics,  charcoal,  and 
gastric  lavage  are  not  recommended  because 
they  can  reintroduce  the  caustic  substance  into 
the  esophagus  and  larynx  and  thus  can  both  in- 
crease the  risk  of  esophageal  perforation  and 
place  the  airway  at  risk. 

Blind  passage  of  a nasogastric  tube  can  re- 
sult in  perforation  of  the  esophagus  or  stomach 
and  is  not  recommended.5  Diluting  agents  such 
as  water  and  milk,  a natural  buffering  solution, 
must  be  used  with  caution  to  avoid  inducing 
emesis.  Antacids  have  been  suggested,  but  their 
value  has  not  been  documented.  Neutralizing 
agents  such  as  vinegar  (for  lye  ingestion)  and 
sodium  bicarbonate  (for  acid  ingestion)  have 
been  used  previously,  but  are  now  criticized.1 
The  neutralizing  reaction  is  highly  exothermic 
and  may  complicate  the  situation  further  with  a 
local  thermal  injury.  Further,  liquid  lye  acts  with 
such  rapidity  and  depth  of  injury  that  neutral- 
izing agents  likely  do  not  retard  damage. 


J La  State  Med  Soc  VOL  152  December  2000  593 


Patients  should  be  admitted  and  prepared 
for  endoscopy  between  24  and  48  hours  after 
injury  and  should  remain  NPO  until  they  are 
able  to  swallow  their  own  saliva.  Grade  I burns, 
as  seen  by  endoscopy,  do  not  require  further 
medical  or  surgical  treatment  and  can  be  fol- 
lowed conservatively.13  Grade  III  transmural 
burns  almost  always  require  urgent  surgery.  The 
value  of  endoscopy  lies  in  its  ability  to  differen- 
tiate Grade  II  injuries,  which  can  often  be  treated 
non-invasively. 

Steroids  are  most  helpful  with  the  preven- 
tion of  stricture  with  Grade  II  injuries.  Numer- 
ous prospective  and  retrospective  series  have 
shown  a significant  decrease  in  stricture  forma- 
tion with  steroid  treatments,  without  reports  of 
death,  increased  infection  rate,  or  gastrointesti- 
nal hemorrhage.14  Some  reports  suggest  that 
strictures  developing  in  steroid-treated  patients 
are  easier  to  manage  than  those  developing  in 
untreated  patients.15  Dosing  is  controversial,  but 
current  recommendations  are  from  1 to  2 mg  per 
kg  per  day  of  prednisone  to  a maximum  dose  of 
60  mg  per  day  tapered  over  a 3-week  course.24 
Steroids  have  shown  little  benefit  for  Grade  III 
injuries  and  may  in  fact  complicate  healing  if 
surgery  is  attempted. 

The  use  of  prophylactic  antibiotics  is  contro- 
versial. Histologic  studies  have  shown  evidence 
of  bacterial  translocation  after  mucosal  injury, 
although  numerous  patient  series  have  failed  to 
show  a change  in  the  rate  of  stricture  formation 
or  infection  rate  with  treatment. 6 

Some  authors  have  advocated  total  parental 
nutrition  for  an  extended  period  to  prevent 
trauma  to  the  gastrointestinal  tract  caused  by 
swallowing,  although  no  controlled  studies  have 
been  completed.16  Lathyrogens  such  as  penicil- 
lamine, which  inhibit  steps  in  the  formation  of 
covalent  crosslinks  between  newly  formed  col- 
lagen molecules,  have  shown  a decrease  in  stric- 
ture formation  in  rats  after  lye  ingestion,  but  no 
studies  in  humans  have  been  published.17  Sev- 
eral authors  have  reported  success  using  intralu- 
minal large-bore  silastic  splints  or  a nasogastric 
tube  as  an  esophageal  prosthesis  to  avoid  stric- 
ture formation.18  Splints  have  been  placed  endo- 


scopically  or  at  the  time  of  surgery.  Some  evi- 
dence would  suggest  that  a splint  should  be  in 
place  for  at  least  3 weeks  to  most  successfully 
treat  stricture  formation. 

Classic  technique  to  avoid  stricture  forma- 
tion is  by  esophageal  dilation,  usually  done  with 
bougienage  starting  2 to  3 weeks  after  the  incit- 
ing injury.  This  process  often  must  be  repeated 
for  an  extended  period.  The  long-term  effective- 
ness is  doubted  by  many  authors,  and  repeated 
dilations  have  been  shown  to  have  a substantial 
risk  of  perforation.4 

Perforation  of  the  stomach  or  esophagus  re- 
quires prompt  surgical  exploration.  Recent  con- 
troversy in  the  management  of  these  injuries  has 
centered  around  the  timing  of  esophagogas- 
trectomy  with  surgical  reconstruction  for  se- 
lected lesions.  Some  centers  advocate  early,  ag- 
gressive reconstructive  surgery  for  Grade  III  and 
many  Grade  II  esophageal  injuries,  although  in- 
dications and  surgical  approach  remain  subjects 
of  controversy.19,20  Most  likely.  Grade  III  burns 
benefit  from  early  surgical  reconstruction.  Grade 
II  lesions  require  careful  consideration,  because 
only  a small  percentage  go  on  to  form  strictures. 

Chronic  esophageal  strictures  unresponsive 
to  dilation  often  require  surgical  reconstruction. 
Cervical  esophageal  resection  and  reanastamosis 
has  been  described.21  Colon  and  jejunal  inter- 
positional  grafts  or  gastric  pull-up  procedures 
have  a significant  risk  of  long-term  dysmotility, 
which  provide  little  advantage  over  the  disabili- 
ties of  stricture.  Careful  patient  selection  is  re- 
quired. 

COMPLICATIONS 

Despite  aggressive  medical  and  surgical  tech- 
niques, approximately  10%  to  20%  of  patients 
with  caustic  burns  go  on  to  develop  strictures, 
particularly  with  circumferential  burns.22  Long- 
term strictures  have  a serious  morbidity,  requir- 
ing repeat  hospitalizations  for  nutritional  short- 
falls, chronic  anemia,  and  repeated  dilations. 
Mortality  from  esophageal  strictures  alone  ap- 
proached 40%  at  the  turn  of  the  century,  and  even 
with  modern  treatments  mortality  has  been  es- 


594  J La  State  Med  Soc  VOL  152  December  2000 


timated  to  vary  from  0%  to  20%.24  The  develop- 
ment of  nasopharyngeal  reflux,  hypopharyngeal 
and  laryngeal  stenosis,  and  tongue  fixation  have 
been  reported  after  caustic  ingestions,  each  lead- 
ing to  significant  functional  morbidity.23 

The  risk  of  esophageal  carcinoma  is  in- 
creased by  1000-fold  25  years  after  a caustic  in- 
jury.4 The  age  of  presentation  in  these  patients  is 
approximately  40  years  old,  which  is  relatively 
younger  than  that  of  the  general  population.  The 
incidence  of  lye  stricture  found  in  patients  with 
esophageal  cancer  is  between  0.8%  and  4.0%.24 

CONCLUSION 

The  ingestion  of  injurious  chemical  substances 
continues  to  pose  a difficult  medical  manage- 
ment problem.  An  understanding  of  the  pattern 
of  injury  and  the  nature  of  varying  forms  of  caus- 
tic and  corrosive  burns  can  help  the  clinician 
make  prudent  decisions  in  the  initial  treatment 
of  these  injuries.  Early  esophagoscopy  and  ste- 
roid treatments  have  significantly  enhanced  ac- 
curate diagnosis  and  treatment  of  caustic 
ingestions,  esophageal  strictures,  and  associated 
injuries. 

REFERENCES 

1.  Howell  JM.  Alkaline  ingestion.  Ann  Emerg  Med 
1986;15:820-825. 

2.  Casasnovas  AB,  Martinez  EE,  Cives  RV,  et  al.  A ret- 
rospective analysis  of  ingestion  of  caustic  sub- 
stances by  children.  Ten-year  statistics  in  Galicia. 
EurJPediatr  1997;156:410-414. 

3.  Christensen  HBT.  Epidemiology  and  prevention  of 
caustic  injury  in  children.  Acta  Paediatr  1994;83:212- 
215. 

4.  Goldman  LP,  Weigert  JM.  Corrosive  substance  in- 
gestion: a review.  Amer  J Gastro  1984;79:85-90. 

5.  Friedman  EM.  Caustic  ingestions  and  foreign  bod- 
ies in  the  aerodigestive  tract  of  children.  Pediatr  Clin 
North  Am  1989;36:1403-1410. 

6.  Moore  WR.  Caustic  ingestions.  Clin  Pediatr 
1985;25:192-196. 

7.  Litovitz  TL.  Button  battery  ingestions.  JAMA 
1988;249:2495-2506. 

8.  Maves  MD,  Carithers  JS,  Birck  HG,  et  al.  Disc  bat- 
tery ingestion.  Ann  Otol  1984;93:364-368. 

9.  Gaudreault  P,  Parent  M,  McGuigan  MA,  et  al.  Pre- 


dictability of  esophageal  injury  from  signs  and  symp- 
toms: a study  of  caustic  ingestion  in  378  children. 
Pediatrics  1983;71:767-770. 

10.  Thompson  JN.  Corrosive  esophageal  injuries:  I.  A 
study  of  nine  cases  of  concurrent  accidental  caus- 
tic ingestion.  Laryngoscope  1987;97:1060-1068. 

11.  Sugawa  C,  Mullins  RJ,  Lucas  CE,  et  al.  The  value  of 
early  endoscopy  following  caustic  ingestion.  SGO 
1981;153:553-556. 

12.  Stannard  MW.  Corrosive  esophagitis  in  children: 
assessment  by  esophagram.  Am  J Dis  Child 
1978;132:596. 

13.  Friedman  EM.  Caustic  ingestion  and  foreign  bod- 
ies in  the  aerodigestive  tract.  In:  Bailey  BJ,  Pillsbury 
HC,  Tardy  ME,  et  al  (editors).  Head  and  Neck  Sur- 
gery-Otolaryngology, 2nd  edition.  Baltimore: 
Lippincott  Williams  & Wilkins;  1998:1159-1167. 

14.  Howell  JM,  Dalsey  WC,  Hartsell  FW,  et  al.  Steroids 
for  treatment  of  corrosive  esophageal  injury:  a sta- 
tistical analysis  of  past  studies.  Am  J Emer  Med 
1992;10:421-425. 

15.  Cardona  JC,  Daly  JF.  Current  management  of  cor- 
rosive esophagitis.  An  evaluation  of  results  in  239 
cases.  Ann  Otol  Rhinol  Laryngol  1971;80:521-527. 

16.  Di  Constanzo  J,  Nouclere  M,  Jouglard  J,  et  al.  New 
therapeutic  approach  to  corrosive  burns  of  the  up- 
per gastrointestinal  tract.  Gut  1980;21:370-375. 

17.  Gehanno  P,  Guidon  C.  Prohibition  of  experimental 
esophageal  lye  strictures  by  penicillamine.  Arch 
Otolaryngol  1981  ;107:145-147. 

18.  Khawaja  FI,  Rajdeo  H.  Endoscopic  placement  of 
intraluminal  stents  for  acute  corrosive  injury  to  the 
esophagus.  GIEndosc  1983;29:163  [abstract]. 

19.  Estrera  A,  Taylor  W,  Mills  LJ,  et  al.  Corrosive  burns 
of  the  esophagus  and  stomach:  a recommendation 
for  an  aggressive  surgical  approach.  Ann  ThoracSurg 
1941:276-283. 

20.  Ritter  FN,  Gago  O,  Kirsh  MM,  et  al.  The  rationale 
of  emergency  esophagogastrectomy  in  the  treat- 
ment of  liquid  caustic  burns  of  the  esophagus  and 
stomach.  Ann  Otol  Rhinol  Laryngol  1971;80:513-520. 

21.  Geller  KA,  Pierce  MK.  Surgical  management  of 
strictures  of  the  cervical  esophagus.  Ann  Otol  Rhinol 
Laryngol  1984;93:505-511. 

22.  Howell  JM,  Dalsey  WC,  Hartsell  FW,  et  al.  Steroids 
for  treatment  of  corrosive  esophageal  injury:  a sta- 
tistical analysis  of  past  studies.  Am  J Emer  Med 
1992;10:421-425. 

23.  Lee  KJ.  Pediatric  otolaryngology.  In:  Lee  KJ  (edi- 
tor). Essential  Otolaryngology,  7th  edition.  Stamford, 
Conn:  Appleton  Lange;  1999:896-897. 

24.  Appleqvist  P,  Salmo  M.  Lye  corrosion  carcinoma  of 
the  esophagus:  a review  of  63  cases.  Cancer 
1980;45:2655-2658. 


J La  State  Med  Soc  VOL  152  December  2000  595 


Dr  Schaffer  is  a resident  in  the  department  of  Otolaryn- 
gology-Head and  Neck  Surgery  Tulane  University 
Medical  Center,  in  New  Orleans , Louisiana. 

Dr  Hebert  is  an  assis  tan  t professor  of  Otolaryngology- 
Head  and  Neck  Surgery  Tulane  University  Medical 
Center  in  New  Orleans ; Louisiana , and  Chief  Of  Oto- 
laryngology-Head and  Neck  Surgery  Veterans  Adminis- 
tration Medical  Center  in  Biloxi , Mississippi. 


GACHASSIN 

L 

AW-  FIRM 

Health  care  contracting 

Regulatory  compliance  and 
government  relations 

Risk  management  and  medical  ! 

malpractice  defense  i 

Fraud  and  abuse/  Stark  compliance 

Medicare  reimbursement  and  appeals 

Health  care  joint  ventures,  mergers  and 
acquisitions 

1026  St.  John  Street 
Post  Office  Box  2850 
Lafayette,  Louisiana  70502 

Telephone:  337*235*4576 
Telefax:  337*235*5003 
E-mail:  gh@gachassin.com 
Web  site:www.gachassin.com 

596  J La  State  Med  Soc  VOL  152  December  2000 





Constipation  Since  Birth 


Harold  R.  Neitzschman,  MD  and  Akshay  S.  Gupta 


A 5-month-old  infant  girl  presents  with  abdominal  pain  and  constipation. 


Figure  2.  AP  erect  view  of 
the  abdomen 


Figure  3.  Lateral  view  of  the  recto- 
sigmoid region  during  single  con- 
trast barium  enema 


What  is  your  diagnosis? 
Elucidation  begins  on  page  598. 


J La  State  Med  Soc  VOL  152  December  2000  597 


Radiology  Case  of  the  Month 
Case  Presentation  is  on  page  597. 

RADIOLOGICAL  DIAGNOSIS  - Hirschsprung's 
disease 

INTERPRETATION  OF  IMAGING 

Figure  1 is  an  AP  flat  view  of  the  abdomen 
demonstrating  prominent  air  filled  loops  of  bowl 
in  the  upper  abdomen.  Figure  2,  an  erect  AP  view 
of  the  abdomen,  shows  a dilated  colon  with  a 
sharp  cut  off  of  air  in  the  rectosigmoid  region. 
There  is  no  free  air  within  the  peritoneum.  Figure 
3 is  a lateral  view  of  the  rectosigmoid  region  on 
barium  enema  demonstrating  a narrowed, 
irregular  distal  colonic  segment.  Notice  the  sharp 
transition  zone,  with  a decreased  rectosigmoid 
ratio.  These  findings  are  consistent  with 
Hirschsprung's  disease. 

DISCUSSION 

Constipation  in  a neonate  or  infant  is  a common 
problem.  Most  often  constipation  is  temporary, 
secondary  to  environmental  factors  and  not 
medically  important;  however,  it  may  be  the  first 
sign  of  a potentially  life  threatening  illness.  A 
dilemma  facing  physicians  is  deciding  when 
constipation  is  medically  significant  and 
warrants  further  investigation. 

Hirschsprung's  disease  is  caused  by  a failure 
of  migration  of  the  enteric  ganglia  derived  from 
neural  crest  cells.  Primitive  neuroblasts  migrate 
in  a cranial  to  caudal  direction  with  complete 
innervation  of  the  colon  at  12-weeks  gestation. 
The  arrest  in  migration  results  in  an  aganglionic 
segment  of  the  distal  colon.  Both  Auerbach's 
plexus  and  Meissner's  plexus  are  absent.1  In  75% 
of  the  cases  the  rectosigmoid  area  is  involved. 
The  entire  colon  is  involved  in  15%  to  20%  of 
the  cases  with  less  than  1%  involving  the  entire 
intestinal  tract.2  Skip  areas  are  extremely  rare  in 
Hirschsprung's  disease.3  The  normal  non- 
stimulated  colon  is  in  a contracted  position  to 
which  peristaltic  waves  cause  progressive 
relaxation  in  a proximal  to  distal  manner.  The 


aganglionic  segment  of  the  bowel  remains  in  a 
contracted  position  leading  to  pseudo- 
obstruction. 

The  incidence  of  Hirschsprung's  disease  is 
1:5000  births  with  up  to  5%  of  the  cases  having 
trisomy  21  (Down  syndrome).  There  is  a 4:1  male 
to  female  predominance  except  in  cases  involv- 
ing the  whole  colon  where  males  and  females 
are  equally  affected.  There  are  no  racial  tenden- 
cies, but  a familial  correlation  exists  in  10%  of 
the  cases.2 

In  the  neonatal  period,  patients  with 
Hirschsprung's  disease  present  with  symptoms 
of  intestinal  obstruction.  Over  90%  demonstrate 
failure  to  pass  meconium  in  the  first  24-48  hours 
of  life  (99%  of  normal  term  babies  pass  meco- 
nium in  the  first  48  hours).1  Infants  often  present 
with  severe,  chronic  constipation.  Twenty  per- 
cent to  30%  of  the  cases  progress  to  enterocoli- 
tis, a potentially  lethal  complication.13  Common 
causes  of  constipation  in  the  neonate  include 
maternal  medication,  neonatal  asphyxia,  bowel 
immaturity,  breast-feeding,  and  meconium  plug 
syndrome.  Less  common  causes  include  Hirsch- 
sprung's disease,  atresia  (anal,  colonic,  ileal), 
cystic  masses  (ovarian,  renal,  mesenteric),  gas- 
trointestinal tract  duplication,  and  incarcerated 
hernia.  In  infants,  psychological  factors  from 
toilet  training  and  metabolic  factors  must  also 
be  considered.1 

The  diagnosis  of  Hirschsprung's  disease  can 
be  strongly  suggested  with  radiographic  stud- 
ies and  anorectal  manometry;  however,  rectal 
biopsy  demonstrating  the  absence  of  ganglia  is 
the  gold  standard.  Anorectal  manometry  mea- 
sures the  reaction  of  the  internal  anal  sphincter 
to  balloon  distension.  Normal  innervated  bowel 
demonstrates  relaxation.  In  Hirschsprung's  dis- 
ease there  is  a failure  of  relaxation  or  paradoxial 
increase  in  pressure.2  The  role  of  the  radiologist 
is  to  confirm  the  diagnosis,  rule  out  other  causes 
of  obstruction,  and  determine  the  length  of  the 
aganglionic  segment.  Plain  films  of  the  abdomen 
will  demonstrate  findings  of  a distal  colonic 
obstruction  with  5%  showing  free  air  from  a 
perforation.  Anon-prepped  barium  enema  is  the 
radiographic  study  of  choice.  Findings  of 


598  J La  State  Med  Soc  VOL  1 52  December  2000 


Hirschsprung's  disease  included  hyperspasticity 
and  narrowing  of  the  distal  bowel  segment,  a 
transition  zone  demonstrating  an  abrupt  change 
in  bowel  caliber,  and  a decreased  rectum  to  sig- 
moid ratio.  The  normal  rectum  is  wider  than  the 
sigmoid  colon.  The  relationship  is  reversed  in 
Hirschsprung's  disease  and  maybe  the  only  clue 
on  a barium  enema.  Other  radiographic  signs 
include  hypertrophy  of  the  proximal  colon 
("jejunalization"),  disordered  evacuation  of  the 
barium  on  a 24-hour  film,  and  loss  of  the  nor- 
mal bowel  redundancy.  Prior  to  definitive  treat- 
ment with  surgical  resection  of  the  aganglionic 
segment  a rectal  biopsy  is  performed.1 

Hirschsprung's  disease  is  a relatively  com- 
mon cause  of  obstruction  in  the  neonate  and 
constipated  infant;  however,  failure  to  diagnose 
the  disease  often  leads  to  significant  morbidity 
and  mortality.  With  a high  index  of  suspicion 
and  proper  ensuing  workup,  Hirschsprung's 
disease  can  be  accurately  diagnosed  and  defini- 
tively treated. 


REFERENCES 

1.  Pearl  RH,  Irish  MS,  Caty  MG.  The  approach  to 
common  abdominal  diagnoses  in  infants  and 
children.  Pediatr  Clin  North  Am  1998;45:1287-1326. 

2.  Miller  KE.  The  child  with  constipation.  In:  Hilton 
SW,  Edwards  DK  (editors).  Practical  Pediatric 
Radiology,  2nd  edition.  Philadelphia,  Pa:  WB 
Saunders;  1994:chapter  8. 

3.  Kirks  DR.  Practical  Pediatric  Imaging:  Diagnostic 
Radiology  of  Infants  and  Children.  3rd  edition. 
Lippincott-Raven;  1998:888-889. 


DrNeitzschman  is  Professor  of  Radiology  and  Pedia  tries 
at  Tulane  University  Health  Sciences  Center  in 
New  Orleans,  Louisiana. 

Dr  Gupta  is  a second-year  Radiology  resident  at  Tulane 
University  Health  Sciences  Center  in 
New  Orleans,  Louisiana. 





Medical  Education  in  19th  Century  Louisiana 

University  of  Louisiana 


Gustavo  A.  Colon,  MD 


In  reviewing  the  old  Journals,  you  come 
across  interesting  articles  about  the  History 
of  Medicine  in  New  Orleans,  Louisiana. 
One  of  them  that  was  fascinating  was  in  the  May 
1861  Journal.  At  that  time,  there  were  two  medi- 
cal schools  in  New  Orleans,  and  they  were  both 
ranked  as  leading  medical  centers  in  the  United 
States.  The  University  of  Louisiana  was  consid- 
ered the  fourth  best  for  medical  education  in  the 
United  States,  while  the  New  Orleans  School  of 
Medicine  was  considered  the  seventh.  In  April 
1861,  both  schools  completed  the  most  success- 
ful years  that  the  New  Orleans  schools  ever  had. 
However,  the  outbreak  of  hostilities  in  April  1861 
ended  one  of  the  best  and  probably  most  pro- 
ductive periods  in  the  History  of  Medical  Edu- 
cation in  the  19th  Century  in  Louisiana.  As  New 
Orleans  rallied  to  the  cause  of  the  Confederacy, 
professors  as  well  as  medical  students  enthusi- 
astically enlisted  in  the  armed  forces.  The  medi- 
cal schools  managed  to  stay  open  until  the  fall 
of  1861,  but,  by  1862,  the  faculty  and  students 


were  depleted  by  the  war  and  the  Federal  occu- 
pation that  caused  their  activities  to  come  to  a 
halt.  What  follows  is  a historical  sketch  written 
by  Stanford  Chaille  and  published  in  May  1961, 
regarding  the  medical  department  of  the  Uni- 
versity of  Louisiana,  which  is  now  Tulane  Uni- 
versity. 

HISTORICAL  SKETCH;  PROFESSORS  AND 
ALUMNI  OF  THE  MEDICAL  DEPARTMENT 
OF  THE  UNIVERSITY  OF  LOUISIANA: 

BY:  STANFORD  E.  CHAILLE  , MD 

'The  history  of  an  institution  from  which  a large 
number  of  our  subscribers  have  received  their 
diplomas,  and  with  whose  labors  and  reputa- 
tion all  of  them  are  familiar,  needs  no  apology 
for  its  publication.  The  author's  connection  with 
the  University,  and  his  personal  relations  to  the 
members  of  the  present  Faculty,  forbid  him  to 
violate  good  taste  by  according  to  each  that 
praise  which  is  deserved  and  which  his  own  feel- 
ings prompt  him  to  bestow.  So  reluctant  is  he  to 


600  J La  State  Med  Soc  VOL  152  December  2000 


be  classed  among  those  whose  words  of  indis- 
criminate laudation,  where  self-interest  is  con- 
cerned, are  framed  to  build  up  reputations  which 
no  acts  have  ever  substantiated,  that  he  invites 
the  reader's  attention  to  an  article  which  has 
been  complied  for  reference  rather  than  unin- 
terrupted perusal  and  which  has  been  limited, 
for  the  reason  suggested,  to  an  unadorned  record 
of  names,  with  a statement  of  tedious  dates,  and 
a dry  summary  of  statistical  data. 

"The  present  Dean,  Prof.  Hunt,  has  permit- 
ted free  access  to  the  records  of  the  Faculty,  and 
has  courteously  contributed  much  information 
and  furnished  every  means  in  his  power  to  ren- 
der accurate  the  facts  cited.  From  his  Reports  to 
the  Legislature,  I have  freely  quoted.  Thanks  are 
due  to  all  the  members  of  the  Faculty  for  valu- 
able aid. 

"The  Medical  College  of  Louisiana,  which 
was  the  predecessor  and  parent  of  the  present 
Medical  Department  of  the  University  of  Loui- 
siana, was  organized  in  New  Orleans  in  Septem- 
ber 1834.  The  prospectus  of  that  year  announced 
that  the  session  would  begin  on  the  first  Mon- 
day in  January  1835,  and  would  terminate  four 
months  thereafter.  The  founders  of  the  College, 
who  constituted  its  first  Faculty,  were: 

♦ Dr  Thomas  Hunt,  Professor  of  Anatomy  and 

Physiology; 

♦ Dr  John  Harrison,  Adjunct  (Demonstrations 

in  Anatomy  by); 

♦ Dr  Ches.  A.  Luzenberg,  Professor  of  Surgery; 

♦ Dr  J.  Monroe  Mackie,  Professor  of  Chemistry; 

♦ Dr  Aug.  H.  Conas,  Professor  of  Midwifery; 

♦ Dr  E.  Bathurst  Smith,  Professor  of  Materia 

Medica. 

"Professor  Hunt,  the  Dean,  delivered  the  first 
introductory  lecture  in  the  presence  of  the  friends 
of  the  undertaking  and  some  eight  medical  stu- 
dents. In  the  circular  issued  by  the  Dean  at  the 
close  of  the  session,  it  was  deemed  a cause  of 
congratulation  that  eleven  students  had  matricu- 
lated during  the  course.  During  the  first  session, 
no  duties  were  discharged  by  Dr  Harrison,  in 
consequence  of  indisposition,  and  Dr  Stone  dem- 
onstrated anatomy.  Dr  Smith  withdrew  from  the 
Faculty  before  the  session  began,  and  Dr  E.H. 


Barton  was  substituted. 

"A  charter  was  granted  to  the  Medical  Col- 
lege by  the  Legislature  on  April  2, 1835,  'and  in 
March  1836,  the  first  degrees  in  science  ever  con- 
ferred in  Louisiana,  were  conferred  by  the  Pro- 
fessors of  the  unendowed  Medical  College.  This 
remarkable  epoch  in  the  scientific  history  of  the 
State  was  succeeded  by  seven  years  of  unre- 
quited and  unaided  professional  labors  by  the 
Faculty,  for  the  advancement  of  medical  science/ 
On  October  20,  1838,  the  Faculty  established  a 
School  of  Pharmacy  for  conferring  the  degree  of 
Doctor  of  Pharmacy. 

"In  1843,  the  Legislature  passed  a bill  grant- 
ing a lease  of  a lot  for  ten  years,  on  the  following 
conditions:  1st.  That  The  Faculty  of  the  College 
should  discharge  the  duties  of  Attending  Physi- 
cians and  of  Surgeons  to  the  Charity  Hospital, 
for  the  term  of  ten  years,  without  compensation/ 
(This  condition  was  complied  with,  thereby  sav- 
ing the  State  $24,000  since  it  had,  prior  to  this 
time,  paid  $2400  per  annum  for  this  service.)  2nd. 
That  the  Faculty  should  'receive  as  students, 
without  fee  or  charge  of  any  kind  for  their  pro- 
fessional services,  one  indigent  person  from  each 
Parish  in  the  State/  etc.  (Under  this  condition, 
and  to  the  present  time,  one  hundred  and  fifty 
students  have  been  educated,  at  a cost  for  their 
education  and  diploma  of  $280  each,  making  a 
sum  total  of  $42,000.)  3rd.  'That  the  building 
erected  on  the  lot  should  become  the  property 
of  the  State  at  the  expiration  of  the  said  term  of 
ten  years.'  (This  building  was  erected  by  the  Fac- 
ulty, and  when  it  became  the  property  of  the 
State,  its  estimated  value  was  $15,000.)  The  edi- 
fice erected  is  now  designated  the  Law  Depart- 
ment of  the  University  of  Louisiana,  and  in  it 
the  lectures  of  the  Medical  College  were  deliv- 
ered during  the  session  of  1843-4,  and  until  1847. 
Prior  to  the  session  of  1843-4,  the  lectures  had 
been  delivered  in  different  years  at  different 
places  — at  No.  41  Royal  Street,  No.  14  St. 
Charles  Street,  No  239  Canal  Street,  and  some 
always  at  the  Charity  Hospital,  in  which  the 
present  amphitheater,  now  the  property  of  the 
State,  was  erected  by  the  Faculty  in  1844,  at  a 
cost  of  $2500. 


J La  State  Med  Soc  VOL  152  December  2000  601 


"In  1845,  the  success  and  fame  of  the  Col- 
lege induced  the  Convention  to  establish,  by  the 
Constitution,  a University  in  New  Orleans,  and 
to  constitute  the  Medical  College,  as  then  orga- 
nized, the  Medical  Department  of  the  Univer- 
sity. In  1847,  the  legislature  appropriated  a lot, 
and  $40,000  to  erect  upon  it  a suitable  building 
for  the  Medical  Department;  and  since  the  ses- 
sion of  1847-8,  this  building  has  been  occupied 
by  the  Faculty  as  designed. 

"In  March  1850,  $25,000  were  appropriated 
by  the  Legislature  for  a museum,  apparatus,  etc.; 
and  subsequently,  $6000  more  for  the  same  pur- 
pose. In  1857,  $12,500  was  given  for  repairing 
the  building,  etc. 

"The  State  has  thus  contributed  in  money  to 
the  Medical  Department,  $83,000. 

"On  the  other  hand,  the  pecuniary  benefits 
conferred  upon,  and  the  value  of  the  property 
transferred  to  the  State  by  the  Medical  Depart- 
ment may  be  fairly  estimated  as  follows: 

"Attendance  upon  the  Charity  Hospital  for 
ten  years,  $24,000;  amphitheater  in  the  same  Hos- 
pital, $2500;  west  wing  of  the  University  build- 
ing, $15,000;  repairs,  insurance,  etc.,  on  the  Col- 
lege edifice,  belonging  to  the  State,  $16,000;  edu- 
cation of  indigent  students,  $42,000  amounting 
in  all  to  $119,500. 

"Besides  these  contributions  to  the  cause  of 
medical  education,  and  to  the  establishment  and 
advancement  of  the  Medical  Department  of  the 
University  of  Louisiana,  the  Faculty  have  matricu- 
lated four  thousand  and  twenty-four  students  in 
the  State  Medical  College.  Each  student  expends 
annually  (at  a very  moderate  calculation),  in 
board,  lodging,  books,  clothes,  etc.,  $500.  Multi- 
ply 4024  by  $500,  the  expenses  of  each,  and  the 
result  is  the  sum  of  two  million  twelve  thousand 
dollars,  which  has  been  introduced  into  and  re- 
mained as  part  of  the  wealth  of  the  State,  through 
the  agency  of  the  Medical  Department  alone. 

"Although  all  the  appropriations  of  the  State 
have  been  enumerated,  the  Legislature  has  at 
various  times  manifested  its  appreciation  of  the 
Medical  Department  of  the  University,  and  bills 
to  augment  its  resources  and  increase  its  useful- 
ness have  from  time  to  time  been  passed  on  by 


the  legislative  houses  without  receiving  the  ap- 
probation of  the  other.  This  occurred  in  1860, 
when  a bill  passed  the  Senate,  but  never  reached 
the  House  in  consequence  of  its  adjournment.  It 
is  confidently  believed  that  at  no  distant  day  the 
Legislature  will  respond  favorably  to  the  prayer 
of  the  Faculty  and  the  report  of  the  Administra- 
tors, who  state  that  the  Faculty  represents  that 
the  institution  has  outgrown  its  accommodations 
— that  it  stands  in  need  of  additional  rooms  for 
lectures,  for  dissection,  etc.,  and  it  prays  your 
honorable  body  to  aid  them  in  this  respect;  and 
further,  to  supply  them  with  the  means  of  en- 
larging and  perfecting  their  museum,  for  the  pur- 
poses of  illustration,  and  of  repairing  and  add- 
ing to  the  clinical  apparatus,  and  of  renewing 
and  increasing  their  specimens  of  materia 
medica,  etc. 

"Surely  an  institution  which,  originating 
twenty-seven  years  ago  with  a class  of  eleven 
students,  has  continued  to  augment  annually  its 
success  and  usefulness  until  it  has  surpassed  in 
the  numbers  of  its  class  nearly  all  of  its  competi- 
tors, now  ranking  as  third  in  North  America, 
deserves  the  patronage  of  the  citizens  of  the  Con- 
federate States,  the  pride  felt  in  it  by  every  en- 
lightened Louisianian,  and  the  fostering  aid  of 
the  State.  With  liberal  and  judicious  assistance 
from  the  State,  with  the  continued  energy  and 
ability  of  its  Faculty,  it  is  destined  to  surpass  the 
enviable  position  it  has  already  acquired,  and  to 
permit  few  if  any  of  its  rivals  to  outstrip  it,  ei- 
ther in  the  number  of  matriculates  or  in  the  edu- 
cational advantages  bestowed  upon  its  gradu- 
ates. What  other  city  contains  such  hospital  privi- 
leges — what  other  such  facilities  for  dissection, 
as  New  Orleans?  And  after  all,  it  is  in  the  hospi- 
tal and  dissecting  room  that  the  medical  student 
must  make  himself  really  a physician.  Seven 
years  ago.  New  Orleans  contained  less  than  two 
hundred  medical  students,  and  these  were  all 
which  were  in  the  cities  on  the  Mexican  Gulf.  In 
1861,  there  were  seven  hundred  medical  stu- 
dents in  Mobile  and  New  Orleans,  and  of  these, 
four  hundred  and  four  in  the  Medical  Depart- 
ment of  the  University  of  Louisiana,  which  has 
pioneered  the  road  that  is  destined  to  make  our 


602  J La  State  Med  Soc  VOL  1 52  December  2000 


city  a great  and  reputable  medical  center. 

"On  March  20,  1861  (since  the  above  was 
written),  a bill  passed  both  houses  of  the  legisla- 
ture, was  approved  by  the  Governor,  and  has 
become  a law,  by  which  the  imposing  and  com- 
modious edifice  known  as  the  East  Wing  of  the 
University  buildings,  formerly  assigned  to  the 
Academic,  was  transferred  to  the  Medical  De- 
partment. This  building  lays  but  a few  yards  dis- 
tance from,  and  by  the  side  of,  the  central  build- 
ing now  used  by  the  Faculty.  These  two  build- 
ings will  probably  be  united  by  suspension 
bridges  connecting  the  corresponding  stories, 
and  will  give  accommodations  unequaled  by 
any  similar  institution  in  the  world,  for  the  ana- 
tomical department,  museum,  and  library.  In  ad- 
dition, there  will  be  rooms  to  devote  to  the  study 
of  operative  surgery  and  obstetrics,  pathology, 
histology,  microscopy,  etc.,  and  each  will  be  fur- 
nished with  all  the  requisites  needed  to  indoc- 
trinate students  in  these  essential  and  practical 
branches  of  their  profession.  Thanks  to  our  leg- 
islature the  demonstrators  will  now  be  forced  to 
turn  none  from  their  doors  for  want  of  sufficient 
room  and  vacant  tables;  and  will  besides  be  en- 
abled to  assign  separate  apartments  to  their  stu- 
dents who  may  become  matriculates  of  the  Uni- 
versity, and  to  furnish  them  agreeable  as  well  as 
efficient  facilities  in  the  prosecution  of  their  ana- 
tomical studies. 

"Every  friend  of  the  old  University,  and  of 
education,  will  rejoice  at  this  wise  munificence 
of  our  legislature;  which,  with  the  inclination  to 
add  an  appropriation  for  such  purchases  and 
repairs  as  are  needed,  deemed  it  wiser  to  reserve 
for  arms  that  which  otherwise  would  have  been 
bestowed  on  science.  Louisiana  has  done  much 
for  our  profession,  will  do  more,  and  all  that  is 
needful,  in  that  future,  not  far  distant,  when  'all 
the  clouds  that  lower  over  our  house  are  in  the 
deep  bosom  of  the  ocean  buried." 

However,  the  ravages  of  war,  occupation, 
and  reconstruction  set  back  medical  education 
for  over  a generation.  Not  until  late  in  the  19th 
Century  did  it  return  to  its  previous  heights. 


Dr  Colon  has  a plastic  surgery  practice  in 
Metairie,  Louisiana.  He  has  lectured  on  the  history  of 
medicine  a t LSU  School  of  Medicine — -New  Orleans, 
and  Tulane  University  School  of  Medicine 
in  New  Orleans,  Louisiana. 

The  author  and  the  Journal  welcome  comments  on 

the  history  of  medicine. 


J La  State  Med  Soc  VOL  152  December  2000  603 


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604  J La  State  Med  Soc  VOL  1 52  December  2000 


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Health  Law  and  Biomedical  Ethics 


Health  Law  and  Biomedical  Ethics: 

An  Introduction 


Joanne  Cain  Marier,  JD 


This  issue  of  the  Journal  of  The  Louisiana 
State  Medical  Society  is  dedicated  to  the 
boundary  of  health  law  and  biomedical 
ethics  from  the  perspectives  of  six  people  who 
are  taking  their  first  steps  in  the  health  profes- 
sions. These  perspectives  are  found  in  papers 
that  were  submitted  to  meet  the  requirements 
of  a course  dealing  with  the  same  subject  this 
year  at  Louisiana  State  University  Health  Sci- 
ences Center  in  New  Orleans.  The  course  itself 
is  offered  as  a core  course  to  students  enrolled 
in  the  MD/MPH  degree  program.  It  is  an  elec- 
tive course  for  students  earning  graduate  de- 
grees in  other  health  professions.  The  papers  call 
attention  to  the  challenges  that  we  face  as  health 
care  professionals  and  as  members  of  society  as 
health  care  moves  into  uncharted  waters  where 
there  are  few  aids  to  navigation,  save  the  ethical 
compass  that  somehow  we  possess. 


What  is  this  ethical  compass  and  how  do  we 
come  to  possess  it?  We  have,  of  course,  the  val- 
ues of  the  medical  profession:  integrity,  respect, 
and  compassion.  We  also  have  the  principles  of 
ethics  that  have  evolved  as  a branch  of  philoso- 
phy, which  deal  with  right  and  wrong  conduct 
and  the  rights  and  corresponding  duties  that  we 
possess  as  individuals  or  as  a society.  In  addi- 
tion we  have  community  standards  that  repre- 
sent generally  accepted  codes  of  conduct. 

Superimposed  on  these  values,  principles, 
and  codes,  we  have  a body  of  laws  and  regula- 
tions (state  and  federal)  and  policies  (institu- 
tional) that  are  more  or  less  actionable  and  cre- 
ate a framework  for  making  decisions  that  will 
be  deemed  permissible,  although  not  always 
sufficient  in  terms  of  the  ethical  principles  or 
values  in  that  choices  may  be  required  where 
the  interests  of  persons  or  society  are  balanced 
or  traded  off  as  the  case  may  be. 


J La  State  Med  Soc  VOL  152  December  2000  605 


Health  Law  and  Biomedical  Ethics 


The  first  set  of  papers  relate  to  the  ability  we 
now  possess  to  alter  the  conditions  of  life  from 
conception  to  death,  and  to  the  ability  to  alter 
the  genetic  codes  that  determine  who  we  will 
be.  The  others  deal  with  more  familiar,  albeit  no 
less  challenging,  problems  in  the  areas  of  domes- 
tic violence  (balancing  the  need  to  protect  pa- 
tients from  abuse  while  respecting  their  confi- 
dentiality interests),  collective  bargaining  (pro- 
fessional conduct)  and  cardiopulmonary  resus- 
citation (resource  allocation). 

Nathan  Markward  writes  about  the  treat- 
ment of  genetic  information  as  intellectual  prop- 
erty, the  controversies  surrounding  the  patent- 
ing of  genetic  sequences  and  related  products 
and  the  efforts  that  restriction  of  information 
may  have  on  health  care  in  the  United  States. 
He  speaks  about  the  need  for  a legal  framework 
for  this  type  of  intellectual  property,  which  will, 
to  a large  extent,  determine  how  advances  in 
genetic  technology  will  be  applied  to  influence 
health  outcomes. 

Danielle  Trepagnier  writes  about  the  impli- 
cations of  human  embryonic  stem  cell  research 
from  a legal  and  ethical  standpoint  and  summa- 
rizes the  recommendations  of  the  National  Bio- 
ethics Advisory  Commission  and  the  concerns 
that  persist  relating  to  the  source  of  the  embry- 
onic stem  cells  and  the  potential  for  exploitation. 

Brooke  Kyle  writes  about  in  vitro  fertiliza- 
tion and  related  legal,  ethical,  and  access  issues 
and  the  potential  harm  to  society  if  a super  race 
were  created. 

Nancy  Kang  has  written  about  domestic  vio- 
lence and  the  role  (responsibility)  that  health  care 
providers  have  with  respect  to  the  people  who 
are  most  affected.  She  calls  for  more  emphasis 
on  this  topic  in  medical  education. 

Benjamin  Canales  takes  on  the  issue  of  Phy- 
sician Unions  - a subject  that  has  polarized  the 
medical  profession  and  society.  He  outlines  the 
need  for  action  at  state  (legislation)  and  local 
(collective  bargaining)  levels  while  cautioning 
against  Union  tactics. 

Larry  Montelibano  provides  an  overview  of 
the  ethical  issues  involved  in  creating  policies 
relating  to  the  use  of  cardiopulmonary  resusci- 


tation with  special  reference  to  factors  contrib- 
uting to  wide  spread  overuse  and  futility  in 
many  settings. 

There  is  much  more  that  needs  to  be  said 
about  these  and  related  topics.  We  hope  to  share 
other  perspectives  from  LSU  Health  Sciences 
Center  in  future  issues  of  the  Journal  of  the  Loui- 
siana Sate  Medical  Society.  We  hope  you  will  share 
your  views  with  us  about  these  topics  and  other 
topics  that  you  would  like  to  see  presented. 


Ms  Marier  serves  as  Chief  of  the  Section  of  Health  Law 
and  Medical  Ethics  on  the  faculty  of  the  Louisiana  State 
University  Health  Sciences  Center  in  New  Orleans. 
She  is  currently  heading  a project  to  integra  te  more 
information  on  medical  ethics  and  health  law  into  the 

medical  school  curriculum. 

The  author  invites  you  to  comment  on  the  legal  and 
ethical  issues  addressed  in  the  featured  articles  in  this 
issue  or  to  make  suggestions  for  future  articles  in 
health  law  and  medical  ethics  by  emailing  her  at: 

jmarie@lsuhsc.edu. 


606  J La  State  Med  Soc  VOL  1 52  December  2000 


Health  Law  and  Biomedical  Ethics 


Intellectual  Property  Law  and 
Genetic  Health  Care 


Nathan  J.  Markward,  MPH 


This  article  provides  a basic  analysis  of  intellectual  property  law,  the  treatment  of  genetic 
information  under  Title  35  of  the  United  States  Code,  the  controversies  surrounding  patenting 
of  genetic  sequences  and  related  products,  and  the  effects  that  restriction  of  information  may 
have  on  the  quality  of  health  care  in  the  United  States.  In  addition,  this  piece  addresses 
technology  transfer  and  historical  developments  in  public  policy  that  have  influenced  patent 
trends.  The  intended  product  is  not  a rigorous  review  of  the  scientific  or  legal  literature,  as  the 
included  cases  have  been  cited  elsewhere  to  accentuate  the  same  points.1  However,  the  compact 
format  of  the  material  should  be  especially  valuable  for  physicians  and  health  personnel  who 
might  not  have  been  exposed  to  these  issues  as  part  of  their  formal  professional  training. 


Revolutionary  advances  in  recom- 
binant DNA  technologies  have 
improved  our  understanding  of  the 
genetic  causes  of  many  debilitating  diseases. 
This  rapid  expansion  of  molecular  technologies 
has,  however,  created  an  impasse  between  ge- 
netic discoveries  and  the  development  of  coher- 
ent public  policies  that  govern  their  applied  uses 
and  dissemination.  The  delay  derives  from  the 
continuing  public  debate  about  the  nature  of 
DNA  and  thwarts  the  development  of  laws  de- 
signed to  set  standards  and  guidelines.  The 
American  legal  system  relies  on  such  models  to 
mold  case  law,  to  define  jurisprudence,  and  to 
enact  legislation  in  diverse  substantive  areas. 

Intellectual  property  law  (IPL)  protects  trade- 
marks, copyrights,  patents,  structural  designs. 


and  confidential  information  that  may  dictate 
commercial  success  or  failure  of  individual  in- 
ventors or  corporate  entities.  The  evolution  of 
IPL  is  an  instructive  example  of  the  symbiotic 
relationship  between  science  and  policy,  because 
the  study  of  human  genetics  has  created  a unique 
forum  to  discuss  how  technological  advances 
and  human  innovation  should  mold  contempo- 
rary social  reality.  IPL  underscores  the  inad- 
equacy of  current  regulations  for  resolving  dis- 
putes over  gene  patents  and  how  revision  of  its 
framework  may  be  of  great  benefit  to  scientists, 
attorneys,  politicians,  and  the  general  public. 

This  article  provides  a basic  analysis  of  intel- 
lectual property  law  (IPL),  the  treatment  of  ge- 
netic information  under  Title  35  of  the  United 
States  Code,  the  controversies  surrounding  pat- 


J La  State  Med  Soc  VOL  152  December  2000  607 


Health  Law  and  Biomedical  Ethics 


enting  of  genetic  sequences  and  related  products, 
and  the  effects  that  restriction  of  information  may 
have  on  the  quality  of  health  care  in  the  United 
States.  In  addition,  this  piece  addresses  technol- 
ogy transfer  and  historical  developments  in  pub- 
lic policy  that  have  influenced  patent  trends.  The 
intended  product  is  not  a rigorous  review  of  the 
scientific  or  legal  literature,  as  the  included  cases 
have  been  cited  elsewhere  to  accentuate  the  same 
points.1  However,  the  compact  format  of  the  ma- 
terial should  be  especially  valuable  for  physicians 
and  health  personnel  who  might  not  have  been 
exposed  to  these  issues  as  part  of  their  formal 
professional  training. 

BACKGROUND 

The  United  States  Constitution  grants  Congress 
the  power  to  enact  laws  relating  to  patents:  "Con- 
gress shall  have  power. . .to  promote  the  progress 
of  science  and  useful  arts,  by  securing  for  lim- 
ited times  to  authors  and  inventors  the  exclu- 
sive right  to  their  respective  writings  and  dis- 
coveries.../72 In  conformance  to  this  privilege. 
Congress  has  intermittently  ratified  legislation 
that  has  either  directly  or  indirectly  affected  the 
patent  process  as  it  relates  to  commercial  and 
academic  innovation.  The  first  patent  law,  en- 
acted in  1790,  exemplified  President  Jefferson's 
widely  recognized  posture  that  "...ingenuity 
should  receive  a liberal  encouragement.7'3  Later 
patent  statutes  were  enacted  in  1793,  1836,  and 
1874,  each  applying  broad  language  to  ensure 
flexibility  of  thought  for  inventors  and  a legal 
means  to  protect  their  ideas.3 

The  more  recent  Patent  Act  of  1952  is  codi- 
fied in  Title  35  of  the  United  States  Code,4  and 
replaced  "art77  with  "process77  in  reference  to  the 
patentable  subject  matter.3  This  law  established 
the  United  States  Patent  and  Trademark  Office 
(PTO)  to  administer  the  laws  and  provisions  re- 
lating to  patents  and  specifies  that  the  right  con- 
ferred by  a patent  grant  is  that  of  "the  right  to 
exclude  others  from  making,  using,  offering  for 
sale,  or  selling"  the  invention  in  the  United  States 
or  "importing"  the  invention  into  the  United 
States.5  The  law  does  not  confer  on  the  patent  ap- 
plicant the  right  to  make,  use,  offer  for  sale,  sell. 


or  import  the  invention. 

Statutory  standards  for  patentability  require 
the  invention  or  product  to  be  (1)  new,6  (2)  use- 
ful,7 (3)  sufficiently  non-obvious  in  view  of  prior 
knowledge,8  and  (4)  described  in  enough  detail 
to  enable  others  working  in  the  same  field  to 
make  and  use  it.9  The  term  of  a new  patent  is  20 
years  from  the  date  on  which  the  application  for 
the  patent  was  filed  in  the  United  States,  or  the 
period  may  begin  from  the  date  of  an  earlier, 
related  application.5  Patent  grants  are  subject  to 
payment  of  maintenance  fees,  and  they  are  ef- 
fective only  within  the  lawful  geographic  bound- 
aries of  the  United  States,  as  well  as  its  territo- 
ries and  possessions.5 

Case  Review 

In  1980,  Diamond  v.  Chakrabarty10  set  the  standard 
for  patenting  microscopic  life  when  the  Supreme 
Court  overturned  a prior  PTO  denial  and 
granted  a patent  for  a genetically  engineered 
bacterium  designed  to  break  down  crude  oil. 
Although  Chakrabarty  did  not  explicitly  address 
the  issue  of  whether  naturally  occurring  products 
were  patentable,  the  Patent  and  Trademark  Of- 
fice has  consistently  granted  patents  for  "inven- 
tions" such  as  isolated  and  sequenced  DNA,  re- 
combinant DNA  vectors,  and  proteins,  classify- 
ing them  as  "new  compositions  of  matter  result- 
ing from  human  intervention.7711012  Patent  ap- 
plicants have  also  reaped  the  benefits  of  the 

. . willingness  of  the  courts  to  uphold  pat- 
ents on  sequences  found  by  obvious  meth- 
ods. The  courts  have  routinely  upheld  pat- 
ents on  novel  chemicals  that  are ' obvious ' 
in  the  sense  that  any  competent  chemist 
would  be  able  to  make  them  ifmotiva  ted  to 
do  so.  Rather  than  assessing  the  obvious- 
ness of  the  method  of  making  a new  chemi- 
cal the  courts  have  focused  on  structural 
and  functional  differences  between  the 
claimed  compound  and  other  compounds  in 
the  'prior  art',  asking  whether  others  in  the 
field  would  have  been  motivated  to  make  the 
new  chemical  and  could  have  envisioned  its 
structure  and  properties. 7/1 


608  J La  State  Med  Soc  VOL  1 52  December  2000 


Health  Law  and  Biomedical  Ethics 


To  further  demarcate  novelty,  the  courts  have 
focused  on  the  differences  between  isolated  com- 
pounds and  those  existing  in  the  prior  art. 

In  the  language  of  encryption  methods,  the 
genetic  code  is  "degenerate"  or  redundant.  In- 
dividual amino  acids  may  be  specified  by  more 
than  one  tri-nucleotide  codon,  each  of  which 
constitutes  a subset  of  the  protein-coding  por- 
tions of  DNA  sequences.  The  following  graphic, 
reproduced  with  permission  from  a table  format- 


ted by  Algorithmic  Arts  and  originally  derived 
from  information  published  by  the  National  In- 
stitutes of  Health  (NIH),  illustrates  these  intri- 
cate points.13  As  explained  in  the  fine  print  at 
the  bottom  of  the  chart,  DNA  sequences  cannot 
be  inferred  directly  from  amino  acid  sequences; 
this  ambiguity  is  the  main  reason  why  the  courts 
have  allowed  individuals  and  corporations  to 
patent  DNA  sequences. 


Table.  20  Amino  acids,  their  single-letter  data-base  codes  (SLC),  and  their  corresponding 
DNA  codons 

Amino  Acid 

SLC 

DNA  Codons 

Isoleucine 

I 

ATT,  ATC,  ATA 

Leucine 

L 

CTT,  CTC,  CTA,  CTG,  TTA,  TTG 

Valine 

V 

GTT,  GTC,  GTA,  GTG 

Phenylalanine 

F 

TTT,  TTC 

Methionine 

M 

ATG 

Cysteine 

C 

TGT,  TGC 

Alanine 

A 

GCT,  GCC,  GCA,  GCG 

Glycine 

G 

GGT,  GGC,  GGA,  GGG 

Proline 

P 

CCT,  CCC,  CCA,  CCG 

Threonine 

T 

ACT,  ACC,  ACA,  ACG 

Serine 

S 

TCT,  TCC,  TCA,  TCG,  AGT,  AGC 

Tyrosine 

T 

TAT,  TAC 

Tryptophan 

W 

TGG 

Glutamine 

Q 

CAA,  CAG 

Asparagine 

N 

AAT,  AAC 

Histidine 

H 

CAT,  CAC 

Glutamic  acid 

E 

GAA,  GAG 

Aspartic  acid 

D 

GAT,  GAC 

Lysine 

K 

AAA,  AAG 

Arginine 

R 

CGT,  CGC,  CGA,  CGG,  AGA,  AGG 

Stop  codons 

Stop 

TAA,  TAG,  TGA 

In  this  table,  the  twenty  amino  adds  foundinproteinsarelisted,  along  with  the  single-letter  code  used  to  represent  these  amino  adds  in protein  data 
bases.  TheDNAcodons  representing  each  amino  add  are  also  listed.  All  64 possible  3-letter  combinations  of  the  DNA  coding  units  T,  QAand  G 
are  used  either  to  encode  one  of  these  amino  adds  or  as  one  of  the  three  stop  codons  tha  t signals  the  end  of  a sequence.  While  DNA  can  be  decoded 
unambiguously  itisnotpossible  topredicta  DNAsequencefromitsprotein  sequence.  Becausemost  amino  addshave  multiple  codons,  anumber 
of possible  DNA  sequences  migh  t represen  t the  same  protein  sequence. 


J La  State  Med  Soc  VOL  152  December  2000  609 


Health  Law  and  Biomedical  Ethics 


Several  nucleotide  sequences  can  encode  the 
same  protein,  whose  function  may  or  may  not 
have  been  determined,  and,  conversely,  a single 
nucleotide  sequence  can  be  alternatively 
spliced — broken  up  and  pieced  together — to 
yield  different  proteins.  Thus,  when  investiga- 
tors filed  a claim  for  the  sequence  encoding  the 
heparin  growth  factor  (HGF),  the  PTO  denied 
the  claim  because  of  the  documentation  of  re- 
lated partial  amino  acid  sequences  in  the  prior 
art.14  A federal  circuit  court  later  reversed  the 
PTO's  holding  and  argued  that  the  degeneracy 
of  the  genetic  code  permits  the  possible  deriva- 
tion of  a single  protein  from  many  different  se- 
quences.14 

The  court's  ruling  in  In  re  Deuel 4 exempli- 
fies how  the  level  of  inventive  skill  necessary  to 
derive  a DNA  sequence  or  its  associated  struc- 
tures has  not  dictated  the  patentability  of  genetic 
material.  This  ruling  also  rejected  a definitive 
stance  regarding  the  physiologic  relevance  of  a 
sequence  in  relation  to  other  DNA  structures  or 
biological  processes.  Indeed,  the  gradual  docu- 
mentation of  hundreds  of  thousands  of  se- 
quences, as  well  as  their  chromosomal  locations 
and  associated  protein  functions,  has  weakened 
the  precedents  of  historical  case  law  in  the  chemi- 
cal arts.  Continued  interface  between  the  bio- 
logical sciences  and  information  technologies 
may  well  place  greater  emphasis  on  the  novelty 
and  non-obviousness  criteria.1  Heightened  sci- 
entific achievement  may  be  met  with  increased 
levels  of  stringency  and  specificity  for  the  issu- 
ance of  patents,  necessitating  a concomitant  re- 
assessment of  current  regulations.  1 

Regarding  the  subject  matter  of  a patent  ap- 
plication, individuals  usually  seek  patent  pro- 
tection for  either  a product  or  a process,  although 
a patent  may  be  granted  to  protect  a related 
"machine"  or  "manufacture,"  as  well.15  Product 
patents  are  granted  to  protect  the  invention  or 
discovery  of  "...any  new  and  useful  machine, 
manufacture,  or  composition  of  matter."15  Prod- 
uct patents  may  be  granted  upon  sufficient 
modification  of  the  old  product  for  use  in  a new 
process,  though  such  modifications  are  pre- 
sumed to  be  obvious  until  unforeseen  proper- 


ties have  been  demonstrated.1  These  patents  are 
not  warranted  for  new  uses  of  old  products, 
though  process  patents  may  be  granted  if  the 
new  use  is  both  novel  and  non-obvious.  Process 
patents  address  a specific  act  or  method,  are 
more  refined  in  scope  and  purpose  than  prod- 
uct patents,  and  often  endure  the  test  of  novelty 
if  the  new  process  sufficiently  deviates  from  the 
previous  application.1 

The  cases  of  In  re  Shetty 16  and  In  re  Dillon 17 
illustrate  these  subtle  points.  In  Shetty , the  ap- 
plicant sought  to  patent  a process  for  a new 
method  of  appetite  suppression  in  animals  with 
adamantane  compounds.  Similar  adamantyl 
compounds  had  been  recorded  in  the  prior  art 
as  a useful  antiviral  agent,  but  the  new  use  as  an 
appetite  suppressant  was  recognized  as  novel 
and  non-obvious.  The  court  awarded  the  pro- 
cess patent  on  these  grounds.  In  Dillon,  a prod- 
uct patent  was  filed  for  use  of  tetra-orthoesters 
in  hydrocarbon  fuels  to  reduce  soot  emissions. 
Tri-orthoesters,  closely  related  compounds,  had 
been  recorded  in  the  prior  art  for  this  purpose, 
and  the  patent  was  denied  based  on  the  chemi- 
cal similarity  of  the  two  compounds. 

Dillon  and  Shetty  may  forecast  restricted 
product  and/or  process  patent  rights  for  those 
who  discover  the  biological  functions  of  previ- 
ously patented  DNA  sequences.1  Under  this  as- 
sumption, few  applications  will  likely  survive 
the  presumption  of  obviousness,  especially  if 
such  functions  are  inherent  properties  recorded 
as  prior  art  (ie,  gene  function).  However,  this 
view  underestimates  the  diversity  of  natural 
genetic  structures,  their  mutability  and  adapt- 
ability, and  the  continued  ingenuity  of  scientists 
to  invent  new  methods  of  alleviating  disease  and 
improving  health  care  based  on  genetic  infor- 
mation. 

Further,  arguments  in  favor  of  DNA  patents 
disregard  two  additional  issues.  First,  product 
patents  on  DNA  sequences,  presumed  to  be 
prima  facie  obvious  products  of  nature,  i.e.  evi- 
dent without  proof  or  reasoning,  should  not 
have  been  granted  in  the  first  place.  Although 
the  Supreme  Court  has  historically  supported 
"that  laws  of  nature,  physical  phenomena,  and 


610  J La  State  Med  Soc  VOL  1 52  December  2000 


Health  Law  and  Biomedical  Ethics 


abstract  ideas  are  not  patentable/'3  lower  courts 
have  seldom  heard  convincing  evidence  derived 
from  mathematics  and  physics  to  support  argu- 
ments for  the  non-patentability  of  DNA.  The 
most  obvious  consequence  of  this  position  is  the 
present  onslaught  of  patent  applications  filed  by 
biotechnology  firms  and  pharmaceutical  corpo- 
rations to  protect  the  gene  and  protein  sequences 
that  have  been  isolated  in  their  laboratories.  Sec- 
ond, even  the  rudimentary  existence  of  gene 
patents  seems  to  contradict  the  Founders'  origi- 
nal intent  of  granting  this  sort  of  exclusive  pro- 
tection to  authors  and  inventors.  In  this  sense, 
the  true  intellectual  properties  that  should  be 
rigidly  assessed  are  the  processes  and  tools  uti- 
lized to  determine  sequences  and  the  myriad 
applications  that  may  be  derived  from  their 
documentation.  Examples  include  the  poly- 
merase chain  reaction  (PCR),  DNA  chip  technol- 
ogy, and  more  recent  developments  in  molecu- 
lar and  biological  computing. 

The  rate  of  issuance  of  product  and  process 
patents  should,  however,  accelerate,  as  better 
knowledge  of  gene  function  leads  to  the  devel- 
opment of  new  technologies  and  treatments.1 
Therefore,  legislative  bodies  will  need  to  enact 
more  concrete  laws  that  regulate  the  rights  to 
new  products  and  processes.  As  the  boundaries 
between  traditional  basic  research  and  corpo- 
rate-driven product  development  have  gradu- 
ally dissipated,  protection  of  intellectual  prop- 
erty has  become  a major  influence  on  market 
strategies  and  research  agendas. 

TECHNOLOGY  TRANSFER 

Technology  transfer  refers  to  the  process  by  which 
information  generated  from  basic  research  is 
acquired  by  private  organizations.18  In  the  case 
of  recombinant  DNA  technology,  this  transfer 
has  involved  the  shift  of  discoveries  from  aca- 
demic laboratories  to  biotechnology  and  phar- 
maceutical firms  which  then  utilize  the  discov- 
eries to  develop  new  applications  based  on  prof- 
itability and  feasibility.18  Biotechnology  firms 
may  choose,  for  example,  to  design  a genetic  test 
or  method  for  rapid  nucleic  acid  analysis  that 


can  be  purchased  by  laboratories  or  profession- 
als in  the  clinical  setting.  Since  World  War  II, 
most  basic  research  has  been  conducted  by  uni- 
versity faculties  who,  under  the  "spirit  of  sci- 
ence" and  academic  freedom,  have  set  standards 
for  ingenuity  and  integrity.19  The  federal  gov- 
ernment and  non-profit  organizations  have 
funded  most  of  these  endeavors  and  generally 
provide  most  resources  for  training  scientists, 
even  today.  They  have  emphasized  the  need  for 
the  free  exchange  of  ideas  through  publishing 
in  peer-reviewed  journals  and  competitive  grant 
processes. 

During  the  1980s,  however,  several  changes 
in  policy  and  reductions  in  non-military-related 
research  spending  permanently  altered  the 
structure  of  research.19  This  change  was  accom- 
panied by  the  rise  of  biotechnology  firms  as  pow- 
erful corporate  entities  and  the  concurrent  for- 
mation of  lucrative  partnerships  between  these 
companies  and  academic  researchers.  Intellec- 
tual property  law  and  amendments  to  the  Patent 
Act  catalyzed  this  movement  and  may  well  have 
undermined  the  dynamics  and  function  of  uni- 
versity-based research. 

Prior  to  1980,  the  Patent  Act  explicitly  man- 
dated that  only  the  federal  government  would 
hold  patents  on  any  inventions  or  products  that 
were  developed  with  public  funds  and  clearly 
established  that  scientists  could  expect  to  receive 
no  monetary  compensation  from  their  inven- 
tions.19 Academic  institutions  and  other  non- 
profit organizations  realized  the  heightened 
value  of  their  research  and  emerged  as  a power- 
ful lobby  to  change  the  federal  guidelines.  Sev- 
eral policies  developed  in  response  to  this  move- 
ment have,  thus,  promoted  an  exponential  in- 
crease in  levels  and  ease  of  technology  transfer. 
Influential  related  policies  are  the  Stevenson- 
Wydler  Technology  Innovation  Agreement  of 
1980  (later  amended  by  the  Federal  Technology 
Transfer  Act  of  1986),  the  Cooperative  Research 
Act  of  1984,  Executive  Order  12591  of  1987,  and 
the  Bayh-Dole  Act  of  1980. 

The  Stevenson-Wydler  Technology  Innova- 
tion Agreement  of  1980  mandated  that  federal 
laboratories  actively  seek  cooperative  research 


J La  State  Med  Soc  VOL  152  December  2000  611 


Health  Law  and  Biomedical  Ethics 


with  state  and  local  governments,  academia, 
non-profit  organizations,  or  private  industry.20 
This  legislation  required  federal  laboratories  to 
disseminate  information  and  to  establish  the 
Center  for  Utilization  of  Federal  Technology  at 
the  National  Technical  Information  Service,  as 
well  as  an  Office  of  Research  and  Technology 
Applications  at  each  federal  laboratory  Federal 
laboratories  are  further  mandated  to  appropri- 
ate 0.50  percent  of  their  fiscal  budgets  to  sup- 
port technology  transfer  activities.  Finally,  this 
legislation  established  the  National  Medal  of 
Technology,  awarded  to  individuals  or  compa- 
nies for  promoting  "technology  or  technologi- 
cal manpower."20 

Stevenson-Wydler  was  later  amended  by  the 
Federal  Technology  Transfer  Act  of  1986,  requir- 
ing scientists  and  engineers  to  be  responsible  for 
and  evaluated  based  on  the  ability  to  transfer 
technology  out  of  the  laboratory.21  Inventors 
from  government-owned,  government-operated 
(GOGO)  laboratories  are  required  to  receive  a 
minimum  of  15  percent  of  all  royalties  gener- 
ated through  patenting  or  licensing.  This  later 
legislation  afforded  federal  employees  the 
luxury  to  participate  in  commercial  develop- 
ment of  technology  if  there  is  no  conflict  of  in- 
terest. 

Technology  transfer  is  further  defined  by  the 
Cooperative  Research  Act  of  1984  (CRA)  and 
Executive  Order  12591  of  1987.2223  The  CRA  re- 
lieved companies  of  the  threat  of  treble  damages 
from  antitrust  suits  when  they  participate  in  joint 
pre-competitive  research  and  development  and 
established  technology  consortia  such  as  the 
Semiconductor  Research  Corporation  and  Mi- 
croelectronics and  Computer  Technology  Cor- 
poration.22 Both  organizations  have  been  influ- 
ential in  providing  a direct  link  between  feder- 
ally funded  engineering  and  physics  research 
and  private  avenues  to  further  develop  appli- 
cable products.  Also,  E.O.  12591  ensures  that 
GOGO  laboratories  can  lawfully  enter  into  co- 
operative research  projects  with  other  federally 
sponsored  laboratories,  as  well  as  state  and  lo- 
cal governments,  universities,  and  the  private 
sector.23 


More  relevant  to  the  topic  of  intellectual 
property  and  the  single  most  affective  piece  of 
legislation  to  date  is  the  Bayh-Dole  Act  of  1980.24 
This  legislation  codified  three  major  changes  to 
the  Patents  and  Trademarks  Act.24  These  alter- 
ations addressed  the  perceived  emphasis  of  uni- 
versities and  non-profit  organizations  in  protect- 
ing their  inventions  and  determining  the  fate  of 
technologies  developed  with  federal  monies. 
First,  it  granted  these  institutions  the  right  to 
claim  title  to  inventions  they  develop  with  fed- 
eral support,  excluding  the  management  and 
operating  contractors  of  federal  laboratories. 
Second,  GOGO  laboratories  were  granted  the 
authority  to  issue  exclusive  licenses  to  patents. 
Third,  descriptions  of  inventions  were  legisla- 
tively protected  from  public  dissemination  and 
requests  for  disclosure  under  the  Freedom  of 
Information  Act  for  a reasonable  period  of  time 
to  file  patent  applications. 

Bayh-Dole  enabled  universities  to  obtain  pat- 
ents and  grant  licenses  from  which  they  could 
receive  substantial  royalties.25  Reciprocally,  pri- 
vate companies  then  increased  their  own  inter- 
est in  federally  funded  projects,  because  univer- 
sities could  now  grant  highly  lucrative,  exclu- 
sive or  non-exclusive,  licenses  to  individual 
firms.26  Exclusive  licenses  grant  the  licensee, 
alone,  rights  to  the  invention  for  no  less  than  17 
years.  Non-exclusive  licenses  grant  access  to 
several  interested  parties  for  a fee.  In  theory,  all 
companies  should  profit  from  the  latter  situa- 
tion, because  it  encourages  greater  rate  of  trans- 
fer and  access  to  information.  As  a result,  uni- 
versities now  generate  substantial  revenues 
through  sophisticated  technology  transfer  offices 
that  work  to  patent  the  intellectual  properties  of 
their  faculty  members,  as  well  as  derive  royal- 
ties from  their  relationships  with  private  re- 
search firms.  This  structure  seems  to  be  consis- 
tent with  the  intended  aims  of  the  1980  amend- 
ments and  has  facilitated  amazing  rates  of  trans- 
fer and  communication  between  universities  and 
the  private  sector. 

Increased  protection  and  support  for  tech- 
nology transfer  have,  however,  been  offset  by 
numerous  new  dilemmas.  Cuts  in  science  spend- 


612  J La  State  Med  Soc  VOL  152  December  2000 


Health  Law  and  Biomedical  Ethics 


ing,  the  rise  of  biotechnology  firms,  and  an  in- 
flux of  scientists  seeking  research  funding  as 
university  junior  faculty  members  during  the 
early  1980s  have  created  several  potential  con- 
flicts of  interest.  These  factors  established  a novel 
cooperative  environment  that  involves  unprec- 
edented intimacy  among  universities,  biotech- 
nology firms,  and  pharmaceutical  corporations. 
An  increasing  proportion  of  research  budgets  are 
being  derived  from  direct  agreements  with  the 
private  sector,  involving  major  long-term  re- 
search funding  in  return  for  exclusive  licenses 
to  patents.  In  particular,  the  intermingling  of 
corporate  and  academic  agendas  has  raised  the 
question  of  whether  or  not  universities  will  be- 
come obligated  subsidiaries  of  private  research 
entities  rather  than  havens  of  intellectual  ex- 
change and  education. 

Ideological  differences  between  the  tradi- 
tional role  of  the  scientist  as  the  "seeker  of  truth" 
and  the  emerging  one  of  entrepreneur  and  ven- 
ture capitalist  are  obvious  and  troublesome. 
Higher  salaries  associated  with  private  sector 
employment,  fewer  tenure-track  faculty  posi- 
tions, and  the  increased  burden  of  debt  faced  by 
today's  graduate  students  all  emphasize  how  the 
paradigm  of  higher  education  and  research 
training  have  been  altered  in  response  to  Bayh- 
Dole.  At  the  very  least,  these  developments  may 
diminish  the  perceived  relevance  of  basic  re- 
search, and  could  well  deplete  the  supply  of 
competent  university  faculty  members,  with 
concomitant  delays  in  publication  of  results  un- 
til after  patent  applications  have  been  filed.  More 
importantly,  greater  input  of  industry  into  basic 
academic  research  could  lead  to  increased  se- 
crecy that  retards  the  rate  of  development  of 
technology  and  widespread  transmittance  of 
genetic-based  treatments  to  the  health  care  sec- 
tor. 

Restricted  access  to  genetic  information  is  an 
extremely  volatile  issue,  because  genetic  testing 
and  risk  assessment  are  rapidly  becoming  an 
integral  part  of  modern  medical  practice.  Phy- 
sicians are  increasingly  responsible  for  inform- 
ing patients  of  how  their  genetic  structures  are 
affecting  their  present  health  or  may  alter  it  in 


the  future.  While  a comprehensive  evaluation 
of  the  ethics  and  law  of  these  dynamics  is  not 
warranted  within  the  present  context  of  patents 
and  intellectual  property,  the  transfer  and  trans- 
mittance of  genetic  technologies  affects  how 
physicians  convey  information  to  their  patients, 
the  treatments  they  prescribe,  and  the  econom- 
ics of  health  care  access  and  delivery.  Cost  is  of- 
ten the  bottom  line,  and  increased  privatization 
of  biomedical  research  could  impress  additional 
constraints  on  the  health  care  infrastructure  as 
corporations  attempt  to  recover  the  expenses  for 
research  and  development,  marketing,  and  pub- 
lic relations.  It  also  may  create  conflicts  of  inter- 
est if  physician-scientists  are  actively  involved 
in  the  research  and  development  of  products 
whose  successful  dissemination  and  utilization 
may  be  laden  with  opportunities  for  financial 
gain  and  professional  advancement. 

The  example  of  one  type  of  DNA  marker,  ex- 
pressed sequence  tag  (EST),  is  not  directly  re- 
lated to  health  care.  However,  it  reveals  how 
patents  may  attenuate  the  exchange  of  informa- 
tion and  ultimately  affect  the  types  and  quality 
of  care  in  the  clinical  setting.  ESTs  are  fragments 
of  DNA  that  serve  as  markers  to  identify  com- 
plete genes  and  protein  functions,  and  scientists 
have  attempted  to  patent  their  sequences  at  vari- 
ous times  over  the  last  10  years.  The  latest  de- 
bate will  likely  set  the  standard  for  future  policy 
and  regulation. 

The  American  Society  of  Human  Genetics 
(ASHG)  originally  rejected  the  thrust  to  patent 
EST,  citing  three  major  concerns.27  First,  the  so- 
ciety believed  that  patenting  of  ESTs  will 
threaten  the  international  collaborative  scope  of 
the  Human  Genome  Project  by  increasing  com- 
petition among  laboratories  and  restricting  in- 
formation exchange.  Second,  ASHG  noted  that 
ESTs  are  not  specific  enough  to  fulfill  the  nov- 
elty requirement,  and  that  granting  such  patents 
would  result  in  competing  arbitrary  claims  for 
the  same  EST  sequence.  Third,  ASHG  suggested 
that  patenting  ESTs  will  inhibit  science  and  pos- 
sibly discourage  companies  and  laboratories 
from  researching  the  genes  and  protein  functions 
associated  with  an  EST  of  interest. 


J La  State  Med  Soc  VOL  152  December  2000  613 


Health  Law  and  Biomedical  Ethics 


The  PTO  considered  several  possible  av- 
enues to  rectify  the  EST  controversy  and  recently 
decided  to  grant  EST  patents  with  their  scope 
limited  only  to  the  sequences  and  uses  stated  in 
the  patent  application.28  This  judicious  approach 
classifies  them  and  certain  other  DNA  fragments 
as  research  and  development  tools  and  allows 
them  to  be  utilized  broadly  as  means  to  develop 
beneficial  technologies  and  treatments.  The  new 
PTO  policy,  however,  does  not  allow  an  EST 
patent  owner  to  charge  licensing  fees  to  indi- 
viduals who  later  determine  the  entire  sequence 
and  function  of  the  gene  containing  the  EST. 
ASHG  later  praised  the  PTO  for  its  stance11 
which  will  make  it  much  more  difficult  to  patent 
EST  molecules  that  are  only  tools  for  further  re- 
search.11'28'29 

CONCLUSIONS 

Recombinant  DNA  technologies  have  already 
been  used  to  determine  the  sequence  of  the  en- 
tire human  genome.  Undoubtedly,  this  valuable 
information  will  greatly  influence  both  lay  and 
scientific  discussions  regarding  human  biology, 
reproduction,  and  ecology  and  will  likely  lead 
to  many  areas  of  debate  at  the  multidisciplinary 
frontier  of  law,  science,  and  social  policy.  Schol- 
ars and  attorneys  will  continue  to  work  at  vari- 
ous levels  of  government,  academia,  and  indus- 
try to  decide  how  genomic  information  should 
best  be  used  to  benefit  each  individual  and  the 
general  population.  Though  this  institutional 
pattern  of  activities  facilitates  a fairly  efficient 
means  for  predicting  at  least  one  driving  force 
of  future  partisan  politics  and  academic  fund- 
ing and  research  activities,  it  does  not  provide  a 
structural  framework  for  the  practice  of  intel- 
lectual property  law  or  the  development  of  eq- 
uitable health  policies.  Integrated  statutory  law 
will  likely  provide  the  only  realistic  avenue  to 
prevent  abuses  in  an  economy  where  informa- 
tion is  restricted  to  those  individuals  who  can 
maintain  expensive  licensing  agreements  with 
patent  holders. 

Establishing  parameters  and  expectations  for 
how  technology  transfer  and  transmittance 


should  impact  medical  practice  is  paramount, 
especially  when  considering  the  fiduciary  na- 
ture of  the  physician-patient  relationship.  Con- 
tinued emphasis  on  patient  autonomy,  informed 
consent,  and  non-directive  counseling  may  place 
an  unmanageable  burden  on  physicians  to  di- 
agnose illness  based  on  their  patients'  genetic 
information,  even  though  most  medical  cur- 
ricula do  not  include  standardized  coursework 
in  medical  genetics  or  comparative  genomics  to 
prepare  them  to  do  so.  In  addition,  physicians 
will  be  challenged  to  explain  this  information  to 
patients  who  vary  considerably  in  socioeco- 
nomic status  and  educational  achievement.  In- 
tellectual property  law,  once  considered  rou- 
tinely mundane,  has  emerged  to  define  how 
these  ethical  decisions  will  be  made  and  how 
advances  in  genetic  technologies  may  be  applied 
to  influence  health  outcomes. 

ACKNOWLEDGMENTS 

The  author  would  like  to  thank  Dr  Mary  Z. 
Pelias,  Dr  Bronya  J.  B.  Keats,  Dr  William  R Fisher, 
and  Professor  Joanne  C.  Marier  of  the  LSU 
Health  Sciences  Center  for  their  constructive 
criticism  and  commitment  to  this  and  associated 
research  projects. 

REFERENCES 

1.  Eisenberg,  RS.  Structure  and  function  of  gene  pat- 
enting. Nat  Genet  1997;15: 125-130. 

2.  United  States  Constitution,  Article  I § 8. 

3.  US  Congress,  Office  of  Technology  Assessment, 
New  Developments  in  Biotechnology:  Pa  ten  ting  Life — 
Special  Report,  OTA-BA-370. Washington,  DC:  US 
Government  Printing  Office;  1989:37. 

4.  35  U.S.  Code  § 101. 

5.  35  U.S.  Code  § 154. 

6.  35  U.S.  Code  § 102. 

7.  35  U.S.  Code  § 101, 112. 

8.  35  U.S.  Code  § 103. 

9.  35  U.S.  Code  § 112. 

10.  Diamond  v.  Chakrabarty,  447  U.S.  303  (1980). 

11.  Funk  Bros.  Seed  Co.  v.  Kalo  Inoculant  Co.,  333  U.S. 
127  (1948). 

12.  Amgen  Inc.  v.  Chugai  Pharmaceutical  Co.,  13 
USPQ2d(BNA)  1737,  1759  (D.  Mass.  1989). 


614  J La  State  Med  Soc  VOL  152  December  2000 


Health  Law  and  Biomedical  Ethics 


13.  National  Institutes  of  Health,  Databases  for  Mo- 
lecular Biology  (visited  7/25/00)  <http:// 
molbio.info.nih.gov/molbio/ geode. html>  and 
http:/ /algoart. com/help/ softstep/  prodocs/ 
aatable.htm  >. 

14.  In  re  Deuel,  51  F.3d  1552  (Fed  Cir.  1995). 

15.  566  F.2d  81, 195  USPQ  (BNA)  753  (CCPA  1977). 

16.  919  F.2d  688  (Fed.  Cir.  1990),  cert,  denied  sub  nom. 
Dillon  v.  Manbeck,  500  U.S.  904  (1991). 

17.  Holtzman,  NA.  Proceed  With  Caution.  Johns 
Hopkins  University  Press;  1989:116. 

18.  Reference  18:117 

19.  Reference  18:118. 

20.  USPL  96-480;  1980. 

21.  USPL  99-502;  1986. 

22.  USPL  98-462;  1984. 

23.  Exec.  Order  No.  12591;  1987. 

24.  USPL  96-480;  1980. 

25.  Reference  18:118-119. 

26.  Reference  18:119. 

27.  American  Society  of  Human  Genetics,  Position  Pa- 
per on  Patenting  of  Expressed  Sequence  Tags  (visited 
4/25/00)  <http:/ /www.faseb.org/ genetics/ ashg/ 
policy /pol-08.htm>. 

28.  Noonan  WD.  Genetic  biotechnology  and  patent 
rights.  Growth  Genetics  and  Hormone;  16(3):41-45. 

29.  American  Society  of  Human  Genetics,  Response  to 
patent  and  trademark  office  (visited  11/1/00)  < 
http://www.faseb.org/genetics/ashg/policy/ pol  - 
39.htm>. 


Mr  Markward  holds  a Master  ofPubhc  Health 
and  is  currently  completing  a PhD  in  the 
Department  of  Genetics  at  Louisiana  State  University 
Health  Sciences  Center  in  New  Orleans , Louisiana. 
He  plans,  eventually  to  persue  a law  degree. 


J La  State  Med  Soc  VOL  152  December  2000  615 


Health  Law  and  Biomedical  Ethics 


Human  Embryonic  Stem  Cell  Research: 
Implications  from  an  Ethical  and  Legal 

Standpoint 


Danielle  M.  Trepagnier,  BA 


The  purpose  of  this  paper  is  to  discuss  the  ethical  and  legal  implications  of  one  of  the  newest 
and  most  controversial  medical  breakthroughs.  Stem  cell  research  has  been  performed  on  mice 
for  many  years,  but  human  embryonic  stem  cells  are  believed  by  scientists  to  be  the  basis  for 
possible  treatments  and/or  cures  to  many  diseases  affecting  millions  of  people  around  the 
world.  In  order  to  perform  research  on  human  embryonic  stem  cells,  numerous  ethical  issues 
must  be  addressed.  Guidelines  and  protocols  can  be  established  in  order  to  allow  scientists  to 
pursue  new  medical  advances  while  maintaining  the  highest  ethical  standards  in  the  use  of 
human  embryos.  An  alternative  to  using  embryos  is  adult  stem  cells  which  have  recently  proven 
to  be  more  versatile  than  previously  believed.  Opposing  views  will  always  be  encountered 
when  facing  new  science  technologies.  Where  should  the  ethical  line  be  drawn? 


Advances  in  science  and  technol- 
ogy have  forced  many  individu- 
als to  address  issues  and  make  deci- 
sions in  circumstances  that  were  once  believed 
unfathomable.  Science  can  cause  conflicts  with 
morals,  ethics,  or  religious  beliefs  among  indi- 
viduals and  community  groups.  While  the  theory 
of  ethics  or  how  to  practically  apply  ethical  be- 
liefs to  actual  situations  is  essential  for  each  in- 
dividual, lawmakers  may  be  called  upon  to  sort 
out  the  facts.  Through  legislative  action,  these 
representatives  of  society  decide  what  ethical 
practice  will  be  followed  on  behalf  of  the  com- 
munities they  represent.  One  of  the  newest  and 


currently  controversial  medical  breakthroughs  is 
the  research  performed  on  human  embryonic 
stem  cells.  Along  with  the  recent  human  genome 
breakthrough,  this  research  is  possibly  the  most 
astounding  development  since  recombinant 
DNA.1  However,  the  issues  involved  in  this  type 
of  research  challenge  ethical  and  definitive  legal 
statutes  and  require  guidelines  and  protocols  to 
serve  to  clarify  the  situational  aspects  of  the  re- 
search for  all  involved.  A compromise  usually  not 
simple  to  accomplish,  must  be  met  on  various 
ethical  issues  from  multiple  perspectives. 

With  many  diseases,  irreversible  damage  to 
cells  and  tissue  occurs.  For  example,  permanent 


616  J La  State  Med  Soc  VOL  1 52  December  2000 


Health  Law  and  Biomedical  Ethics 


damage  occurs  with  diabetes  to  the  beta  cell 
destruction  on  the  islet  cells  of  the  pancreas  and 
Parkinson's  disease  on  neurons  of  the  brain.1'3 
The  ultimate  outcome  for  researchers  would  be 
to  culture  human  cells  that  could  colonize  and 
regenerate  failing  tissue.4  Much  as  cancer  cells 
can  grow  outside  the  body,  the  researchers'  goal 
is  to  grow  healthy  cells  outside  the  body  that 
could  be  used  to  aid  diseased  patients.  This  cre- 
ates an  ethical  issue  as  to  the  use  of  embryos  for 
stem  cell  research.  Also,  do  the  possible  benefits 
of  this  type  of  research  to  society  outweigh  moral 
obligation? 

STEM  CELLS:  DEFINITION  AND  THE 
ETHICAL  PROBLEM 

As  stated  in  the  executive  summary  of  the  Na- 
tional Bioethics  Advisory  Commission  (NBAC), 
"the  stem  cell  is  a unique  and  essential  cell  type 
found  in  animals;  and  many  kinds  of  these  cells 
are  found  in  the  body."5  When  stem  cells  divide, 
some  mature  into  specific  types  such  as  heart, 
blood,  muscle,  or  brain  cells,  while  others  remain 
stem  cells  on  "standby"  to  repair  everyday  wear 
to  the  body.  The  "standby"  stem  cells  are  capable 
of  constantly  reproducing  themselves  and  re- 
plenishing tissue  throughout  one's  life.  These 
cells,  for  example,  revitalize  skin  and  regener- 
ate the  gut  lining.6  The  best  condition  of  the  stem 
cells  is  found  in  the  early  stage  embryo.  The 
embryonic  stem  (ES)  cells  have  greater  capabil- 
ity to  develop  into  other  cell  types  than  adult 
stem  cells  or  umbilical  cord  blood.7  Another  type 
is  embryonic  germ  (EG)  cells,  which  originate 
from  the  primordial  reproductive  cells  of  the 
developing  fetus.  The  EG  cells  resemble  the  ES 
cells,  but  researchers  have  stated  that  the  EG  cells 
do  not  offer  as  many  benefits.  Researcher  Azim 
Surani  of  the  Wellcome /CRC  Institute  of  Can- 
cer and  Developmental  Biology  in  Cambridge, 
U.K.  provided  evidence  that  mouse  EG  cells 
implanted  into  early  mouse  embryos  can  cause 
abnormalities.8  The  EG  cells  seem  to  "lack  cer- 
tain modifications  needed  for  their  normal  ac- 
tivity during  development."8 

There  are  currently  four  sources  of  human 
stem  cells:  (1)  EG  cells  from  cadaveric  human 


fetal  tissue  following  elective  abortion;  (2)  ES 
cells  from  human  embryos  that  are  created  by 
in  vitro  fertilization  (IVF),  but  are  no  longer 
needed  by  couples  being  treated  for  infertility; 
(3)  ES  cells  from  human  embryos  that  are  cre- 
ated by  IVF  means  for  the  sole  purpose  of  re- 
search; and  (4)  ES  cells  derived  from  human  or 
hybrid  embryos  generated  asexually  by  somatic 
cell  nuclear  transfer  or  similar  cloning  tech- 
niques.5 The  EG  cells  from  cadaveric  fetal  tissue 
is  most  accepted  because  it  is  similar  to  other 
uses  of  tissues  or  organs  from  deceased  persons. 
Cadaveric  fetal  tissue  is  acquired  from  elective 
abortions  which  is  strongly  opposed  by  anti- 
abortion activists.  Of  the  four  sources,  the  stron- 
gest opposition  is  toward  the  source  of  created 
embryos  for  the  sole  purpose  of  use  in  research 
experiments. 

Mouse  ES  cell  research  has  been  ongoing  for 
approximately  2 decades,9  and  human  embry- 
onic stem  cell  research  has  been  mostly  done 
through  private  funding.  Human  embryonic 
stem  cell  research  can  possibly  provide  treat- 
ments for  diabetes,7  heart  disease,710  stroke,10 
spinal  cord  injury,11'12  rheumatoid  arthritis,12 
trauma,  Parkinson's  disease,713  Alzheimer's  dis- 
ease,7 cancer,711  muscular  dystrophy,14  multiple 
sclerosis,14  sickle-cell  anemia,15  HIV,  lupus,  and 
genetic  diseases  and  abnormalities.16  Its  possi- 
bilities include  stem  cell  transplants;17  patient 
immune  system  tolerance  to  prevent  rejection 
of  transplants;  regeneration  of  injured  cartilage 
and  other  types  of  tissue;  gene  therapy;16  dopam- 
ine-producing neurons  for  Parkinson's  dis- 
ease;12'3 cells  for  brain,  nerve,  and  heart  grafts;1,3 
myocardiocytes  injected  into  the  heart  to  heal 
myopathies  and  scars;2  insulin-producing  pan- 
creatic beta  cells  to  treat  or  possibly  even  cure 
diabetes;1'3  enhanced  understanding  of  birth 
defects;15  and  ways  of  testing  teratogens  and  new 
drugs.6,15'17 

HISTORICAL  TIMELINE 

In  1991,  Irving  L.  Weissman  of  Stanford  Univer- 
sity discovered  a type  of  human  stem  cell  found 
in  bone  marrow.  "A  cancer  patient  whose  mar- 
row has  been  destroyed  by  high  doses  of  radia- 


J La  State  Med  Soc  VOL  1 52  December  2000  617 


Health  Law  and  Biomedical  Ethics 


tion  or  chemotherapy  can  be  saved  by  a trans- 
plant of  bone  marrow-derived  cells/'4  Since,  this 
discovery,  researchers  have  found  stem  cells  in 
tissues  of  the  brain,  pancreatic  islet,  and  liver. 
Researchers  for  several  companies  are  attempt- 
ing to  extract  stem  cells  from  a tissue  sample 
provided  by  a donor  or  patient,  then  multiply 
the  stem  cells  in  the  laboratory.  This  practice  is 
also  being  used  as  an  experimental  treatment  for 
breast  cancer.18 

In  November  1998,  two  academic  biologists 
revealed  that  they  had  established  long-lived 
cultures  of  human  stem  cells.  James  Thomson 
of  the  University  of  Wisconsin  (UW),  Madison, 
and  John  Gearhart  of  The  Johns  Hopkins  Uni- 
versity in  Baltimore  have  been  the  next  two  re- 
searchers in  line  to  tread  the  stem  cell  research 
waters.  Dr  Gearhart,  along  with  others,  "predict 
that  within  10  to  20  years  it  will  be  possible  to 
grow  healthy  neurons  to  replace  damaged  brain 
cells  in  people  with  Parkinson's  disease."13  Dr 
Gearhart's  cells  are  derived  from  aborted  fetuses, 
so  he  has  received  less  controversy  over  his  re- 
search.13 Since  the  1970s,  federal  guidelines  have 
permitted  some  fetal  tissue  research  on  aborted 
fetuses  if  the  abortion  clinic  and  the  research 
laboratory  were  unrelated.  Dr  Thomson's  cells 
came  from  embryos  donated  to  research  by 
couples  who  had  undergone  in  vitro  fertiliza- 
tion procedures.13  A patent  and  license  have  been 
placed  on  the  techniques  developed  by 
Thomson's  research  group. 

James  Thomson's  work  at  UW-Madison  pro- 
gressed another  step  when  on  February  1,  2000, 
the  university  announced  that  they  created  a 
non-profit  research  institute  to  distribute  their 
embryonic  stem  cell  line.  The  institute  named 
WiCell  Research  Institute  was  set  up  by  the  Wis- 
consin Alumni  Research  Foundation  (WARF) 
which  was  one  of  Thomson's  research  support- 
ers and  also  owns  the  patent.  After  careful  re- 
view of  research  plans  "to  make  sure  the  cells 
are  used  appropriately  and  with  adequate  re- 
spect", WiCell  planned  to  begin  distributing 
stem  cells  to  scientists  in  late  Spring  2000.3  Re- 
strictions include  stem  cells'  exclusion  from  clon- 
ing experiments  or  mixture  with  intact  embryos. 


A one-time  fee  of  $5,000  for  two  vials  of  cells  is 
the  cost  which  is  to  cover  quality  control  and 
technical  support  for  the  care  of  the  cells.  By 
March  2000,  "Dr  Thomson's  lab  had  already  re- 
ceived over  100  requests  for  cells,  several  of 
which  were  from  private  companies."19  More 
information  about  the  WiCell  Institute  may  be 
obtained  at  their  website:  www.wicell.org/ 
index2.html. 

At  a National  Bioethics  Advisory  Commis- 
sion (NBAC)  meeting  in  January  1999,  the  US 
Department  of  Health  and  Human  Services 
(DHHS)  issued  a legal  opinion  of  their  interpre- 
tation of  the  congressional  ban.  They  stated  that 
human  embryonic  stem  cell  research  is  not  in- 
cluded under  the  ban  on  federal  funding  for 
human  embryo  research.17  According  to  the  fed- 
eral ban,  concern  was  placed  on  the  human 
embryos  being  "harmed  or  destroyed".  The 
loophole  was  that  even  though  the  stem  cells 
come  from  human  embryos,  they  are  technically 
not  embryos  nor  can  they  ever  develop  into  a 
fully  functioning  human  being.  Therefore, 
Harriett  Rabb,  general  counsel  of  the  DHHS  re- 
ported that  the  research  could  be  done  on  the 
extracted  cells.20  The  interpretation  by  DHHS 
was  refuted  by  Congress  when  70  members 
signed  a letter  of  objection,21  and  the  ban  held  to 
include  embryonic  stem  cell  research.  Embryo 
research  was  banned  from  federal  funding, 
where  it  could  be  openly  regulated,  but  the  re- 
search has  been  allowed  to  proceed  mostly  un- 
regulated within  the  private  sector.1  Research  is 
going  forward  with  OR  without  federal  fund- 
ing. Other  countries,  such  as  the  U.K.  and  Ja- 
pan, are  also  jumping  into  the  pool  of  stem  cell 
research.  For  more  than  10  years,  a Swedish  neu- 
roscientist and  his  team  at  Lund  University  have 
been  using  aborted  fetuses  for  grafting  neurons 
in  brains  of  patients  with  Parkinson's.22 

As  a result  of  President  Clinton's  request,  the 
National  Bioethics  Advisory  Commission  issued 
an  executive  summary  report  in  September  1999 
on  "Ethical  Issues  in  Human  Stem  Cell  Re- 
search."5 This  report  states  recommendations  on 
how  to  handle  the  issue  considering  all  medical 
and  ethical  aspects  (Table  1).  The  two  important 


618  J La  State  Med  Soc  VOL  152  December  2000 


Health  Law  and  Biomedical  Ethics 


Table  1.  National  Bioethics  Advisory  Commission  Executive  Summary  on  “Ethical  Issues  in 
Human  Stem  Cell  Research”  Conclusions  and  Recommendations  5 

A. 

The  Ethical  Acceptability  of  Federal  Funding  of  ES  and  EG  Cell  Research  by  the  Source  of  the  Material: 
Federal  funding  for  the  use  and  derivation  of  ES  and  EG  cells  should  be  limited  to  two  sources  of  such 
material:  cadaveric  fetal  tissue  and  embryos  remaining  after  infertility  treatments. 

B. 

Requirements  for  the  Donation  of  Cadaveric  Fetal  Tissue  and  Embryos  for  Research:  It  is  important,  when- 
ever possible,  to  separate  donors'  decisions  to  dispose  of  their  embryos  from  their  decisions  to  donate  them 
for  research. 

C. 

The  Need  for  National  Oversight  and  Review:  Given  the  heightened  sensitivity  of  this  research,  an  over- 
sight and  review  panel  would  be  given  a set  of  duties  to  follow.  "No  such  system  currently  exists  in  the 
U.S."  (NBAC). 

D. 

The  Need  for  Local  Review  of  Derivation  Protocols:  Institutional  review  of  protocols  to  derive  stem  cells. 

E. 

Responsibilities  of  Federal  Research  Agencies:  Sponsoring  agency  review  of  research  use  of  stem  cells. 

F. 

Attention  to  Issues  for  the  Private  Sector:  Voluntary  actions  by  private  sponsors  of  research  that  would  and 
would  not  be  eligible  for  federal  funding. 

G. 

The  Need  for  Ongoing  Review  and  Assessment:  To  evaluate  its  effectiveness,  value,  and  ongoing  need. 

Source:  Na  tional  Bioethics  Advisory  Commission.  ( 1 999).  Ethical  Issues  in  Human  Stem  Cell  Research  - Execu  tive  Summary. 
Rockville,  MD.  Sep  1999.  www.bioethics.gov. 


ethical  "commitments"  are  (1)  to  cure  disease 
and  (2)  to  protect  human  life  as  stated  by  the 
NBAC.  Since  a major  concern  of  the  public  is 
where  the  embryos  are  acquired,  NBAC  deter- 
mined they  are  not  to  be  created  for  the  sole 
purpose  of  research  as  already  stated  in  the  fed- 
eral legislation.  Also,  the  aborted  fetuses  used 
in  EG  cell  research  are  to  be  donated  from  elec- 
tive abortions  and  not  through  persuasion  to 
abort  for  the  purpose  of  donation.  In  other 
words,  guidelines  will  "insure  that  the  use  of 
the  tissues  in  research  in  no  way  induces  a 
woman  to  have  an  abortion."23  There  should  be 
no  money  market  for  the  selling  of  fetuses  or 
embryos.  This  possibly  could  prevent  a black 
market  for  embryos  and  fetuses  since  no  incen- 
tives can  be  offered  for  the  donations. 

In  December  1999,  NIH  published  draft 
guidelines  in  the  Federal  Register  and  accepted 
public  comments.24  Then  in  August  2000,  NIH 
disclosed  its  revised  final  guidelines  and  added 
them  to  the  Federal  Register.  These  guidelines 
will  allow  federal  funding  for  selected  scientists 


to  perform  embryonic  research  only  by  follow- 
ing ethical  and  scientific  criteria  set  by  the  NIH.25 

Funding  applications  will  be  reviewed  by 
two  oversight  committees  composed  of  scien- 
tists and  ethicists.  Researchers  are  not  allowed 
to  extract  their  own  stem  cells  but  must  obtain 
them  from  private  sources.  The  cells  are  to  come 
from  surplus  frozen  embryos  that  would  other- 
wise be  destroyed.  Donors  are  not  to  receive 
payments  or  choose  the  recipients  of  their  stem 
cells.  This  concept  is  similar  to  the  NBAC  guide- 
lines to  make  an  effort  in  controlling  the  market 
for  embryos. 

Legally  it  is  hard  to  include  all  scenarios  in 
lawmaking  to  serve  as  guidelines  for  policies. 
Interpretations  can  vary,  especially  to  one's  favor 
when  deemed  necessary.  It  then  becomes  man- 
datory that  changes  and  revisions  be  made  to 
rulings  and  additions  made  based  on  unforseen 
legal  and  ethical  issues.  Establishing  protocols, 
guidelines,  and  oversight  committees  are  needed 
as  research  and  science  advance  to  make  sure 
materials  and  techniques  are  not  abused. 


J La  State  Med  Soc  VOL  152  December  2000  619 


Health  Law  and  Biomedical  Ethics 


Between  January  and  February  of  2000,  two 
bills  were  introduced  in  Congress  to  allow  fed- 
eral funding.  The  first  titled,  "Stem  Cell  Research 
Act  of  2000"  S.2015  was  presented  by  Senator 
Arlen  Specter  (R-PA)  and  Senator  Tom  Harkin 
(D-IA),  and  "calls  for  allowing  federally  funded 
scientists  to  derive  their  own  human  pluripo- 
tent  stem  cells  from  human  embryos."2627  The 
second  was  entitled  H.Res.414  presented  by  Rep- 
resentative Carolyn  Maloney  (D-NY).  A synop- 
sis of  this  bill  was  "a  resolution  expressing  the 
sense  of  the  House  of  Representatives  support- 
ing Federal  funding  directed  toward  human 
pluripotent  stem  cell  research  to  further  research 
into  Parkinson's  and  other  medical  condi- 
tions."28 Various  scientists,  activists,  and  celeb- 
rities visited  Capitol  Hill  on  September  14, 2000, 
to  have  their  voices  heard  by  the  Senate  subcom- 
mittee on  Labor,  Health  and  Human  Services 
and  Education  concerning  stem  cell  research  is- 
sues.29 

EMBRYONIC  STEM  CELLS 
v.  ADULT  STEM  CELLS 

The  reason  to  use  embryonic  stem  cells  as  op- 
posed to  adult  stem  cells  is  that  the  adult  stem 
cells  are  believed  to  age  prematurely,  which  lim- 
its their  growth  potential.  Embryonic  stem  cells 
are  claimed  by  researchers  to  be  more  versatile. 
Through  bioengineering  techniques,  animal 
embryonic  stem  cells  are  able  to  be  cultured  in- 
definitely and  can  give  rise  to  every  cell  type 
found  in  the  body.4  One  example  of  this  ability 
was  displayed  by  Loren  J.  Field  and  his  associ- 
ates at  Indiana  University.  They  made  heart 
muscle  cells  from  mouse  embryonic  stem  cells 
by  adding  specific  DNA  sequences  to  them.  "The 
resulting  cells  engraft  in  a developing  heart."4 
Such  possibilities  tell  the  public  that  human 
embryonic  stem  cell  research  could  provide 
countless  treatments  of  human  diseases.  Re- 
searchers noted  one  major  setback.  Six  fetuses 
are  needed  to  derive  enough  stem  cells  for  treat- 
ment of  one  Parkinson's  patient  because  ap- 
proximately "90%  to  95%  of  the  neurons  die 
shortly  after  grafting."22  John  Sladek,  chair  of 


neuroscience  at  Chicago  Medical  School,  stated 
that  even  if  fetal-cell  die  off  is  diminished  by  find- 
ing better  techniques,  "there  will  never  be  enough 
fetuses  available  to  make  this  (Parkinson's  treat- 
ment) an  'everyday  procedure'."22 

Recent  studies  have  shown  that  adult  stem 
cells  are  more  versatile  than  once  believed.  This 
finding  provides  a viable  alternative  to  embry- 
onic stem  cell  use  in  research.  As  of  this  fall,  new 
essential  findings  are  being  reported  almost  on 
a daily  basis  from  numerous  laboratories.  In  Sep- 
tember 2000,  a group  named  "Do  No  Harm:  The 
Coalition  of  Americans  for  Research  Ethics 
(CARE)",  specially  noted  current  human  clini- 
cal applications  that  successfully  use  adult  stem 
cells  which  consisted  of:  cancer  treatments  (brain 
tumors,  ovarian  cancer,  solid  tumors,  multiple 
myeloma,  breast  cancer,  non-Hodgkin's  lym- 
phoma), autoimmune  diseases  (multiple  sclero- 
sis, systemic  lupus,  juvenile  rheumatoid  arthri- 
tis, rheumatoid  arthritis),  anemia,  stroke,  corneal 
scarring,  osteogenesis  imperfecta,  and  gene 
therapy.30  Specific  cases  using  adult  stem  cells 
are  noted  in  Table  2.  According  to  the  CARE, 
"Embryonic  stem  cells  have  yet  to  produce  a 
single  benefit  for  human  patients,  while  adult 
stem  cells  have  already  proved  beneficial."30  If 
adult  stem  cells  truly  are  just  as  versatile  as  em- 
bryonic stem  cells,  it  may  allow  researchers  an 
escape  from  the  entire  embryo  ethical  issues.  Dr 
Nick  Wright,  professor  at  the  Imperial  Cancer 
Research  Fund,  a researcher  currently  perform- 
ing human  adult  bone  marrow  stem  cell  trans- 
plantation into  liver  tissue,  stated  that  his  team's 
technique  does  not  have  the  ethical  limitations 
of  using  embryo  stem  cells.31  In  summary,  adult 
stem  cell  use  would:  (1)  perform  versatile  tasks 
that  were  not  believed  possible,  (2)  avoid  the 
ethical  issue  of  embryo  use,  and  (3)  reduce  re- 
jection of  foreign  organ/matter  because  the 
patient's  cells  are  transplanted  back  into  the 
same  patient.  Dr  Markus  Grompe,  professor  of 
molecular  medical  genetics  at  Oregon  Health 
Sciences  University,  stated,  "This  would  suggest 
that  maybe  you  don't  need  any  type  of  fetal  stem 
cell  at  all  - that  our  adult  bodies  continue  to  have 
stem  cells  that  can  do  this  stuff."31 


620  J La  State  Med  Soc  VOL  1 52  December  2000 


Health  Law  and  Biomedical  Ethics 


Table  2.  Recent  Adult  Stem  Cell  Research  Advancements  3031 

France  uses  human  adult  stem  cells  for  gene  therapy  treatment  on  infants  with  severe  combined  immunodefi- 
ciency (SCID)-Xl  disease 

University  of  Florida  reversed  diabetes  in  mice  using  adult  pancreatic  stem  cells 

St.  Jude  Children's  Hospital  in  Memphis  transplanted  bone  marrow  stem  cells  to  treat  children  with  osteogenesis 
imperfecta,  a cartilage  defect 

Harvard  Medical  School  transplanted  neural  stem  cells  of  mice  to  decrease  tremors  in  mice  modeled  for  Parkinson's 
and  other  CNS  diseases 


Japan  transplanted  adult  corneal  stem  cells  to  improve  vision  to  legally  blind  recipients 
U.S.  and  U.K.  transplanted  human  adult  stem  cells  from  bone  marrow  to  grow  new  liver  tissue 


Source:  DoNoHarm:The  Coalition  of  Americans  for  Research  Ethics  (2000).  Stem  Cell  Report:  Advances  in  Alternatives  to 
Embryonic  Stem  Cell  Research.  June 2000 and  July/ August 2000.  www.stemcellresearch.org 


SCIENCE  v.  BELIEFS 

Since  stem  cell  research  involves  ethical  dilem- 
mas, universal  public  support  is  lacking,  which 
in  turn  prevents  progression  of  research  in  this 
area.  Many  may  be  opposed  to  embryos  being 
used  in  this  research  because  of  personal  feel- 
ings, and/ or  religious  beliefs,  and/ or  coercion 
from  others.  An  issue  often  cited  in  abortion 
debates  is:  When  does  life  begin?  This  contro- 
versial idea  can  also  be  applied  to  this  scenario. 
"Since  modern  discoveries  in  the  fields  of 
anatomy  and  biology,  the  Church's  condemna- 
tion of  abortion  has  made  no  official  distinctions 
regarding  the  different  stages  of  development 
of  human  embryos."33  Is  embryonic  stem  cell 
research  a matter  of  taking  one  life  to  save  an- 
other? There  are  numerous  positions  one  can 
take  to  support  or  oppose  the  use  of  embryos  in 
research  depending  on  how  each  individual  feels 
about  the  issue. 

The  opposition  to  embryonic  stem  cell  re- 
search is  substantial.  Georgetown,  a Catholic 
university,  opposed  the  stem  cell  research  when 
Dr  Mark  Fiughes  was  on  contract  with  them.  Dr 
Hughes  is  a geneticist  who  also  worked  at  NIH 
testing  DNA  from  human  embryo  cells  for  gene 
abnormalities.34  Anti-abortion  groups  along  with 
Governor  Mike  Johanns  of  Nebraska  battled 


against  the  University  of  Nebraska,  its  president, 
and  researchers  over  their  human  fetal  tissue 
research  on  the  study  of  Alzheimer 's  disease  and 
HIV.35  Nature  Magazine  reported  in  August  1999 
that  the  American  Cancer  Society  withdrew  from 
their  relationship  with  the  Patients'  Coalition  for 
Urgent  Research  ("Patients'  CURe")  once  they 
received  pressure  from  Catholic  church  officials 
and  pro-life  activists.36  Many  members  of 
Patient's  CURe  were  pressured  to  withdraw,  but 
some  resisted.36  Senator  Arlen  Specter  is  chair 
of  the  appropriations  subcommittee  that  funds 
NIH17  and  has  faced  opposition  from:  (1)  Sena- 
tor Sam  Brownback  (R-KS)  who  "equates  stem- 
cell extraction  and  research  with  Nazi  experi- 
ments"37; and  (2)  Representative  Jay  Dickey  (R- 
AR),  "who  has  equated  stem  cell  research  to  the 
experiments  in  Nazi  Germany  and  the  Tuskegee 
syphilis  experiments."26  Many  individuals,  some 
on  the  behalf  of  organizations,  are  forced  into 
decisions  based  on  pressure  from  outside  enti- 
ties. Yet,  many  are  just  airing  their  personal  be- 
liefs and  judgments. 

A longstanding  controversy  in  research  has 
been  the  use  of  animals  in  experiments.  The  re- 
cently released  NIH  guidelines  reflect  that  the 
advancement  of  stem  cell  research  can  eliminate 
the  need  for  animals  in  research.  Not  surpris- 
ingly then,  the  People  for  the  Ethical  Treatment 


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Health  Law  and  Biomedical  Ethics 


of  Animals  (PETA)  is  also  supporting  embryo 
use  "as  an  alternative  to  the  use  of  laboratory 
mice,  rats,  and  other  animals  in  the  testing  of 
chemicals,  household  products,  and  pharmaceu- 
ticals."38 In  a plea  to  the  scientific  community, 
the  National  Catholic  Bioethics  Center  states  in 
response  to  NIH's  and  PETA's  actions,  "No  one 
wishes  to  see  God's  creatures  needlessly 
harmed,  but  surely  it  is  a fanatical  view  to  hold 
that  the  lives  of  animals  are  more  valuable  than 
those  of  human  beings."38 

Another  proponent,  the  American  Heart  As- 
sociation proposed  in  June  2000  to  endorse  stem 
cell  research  when  the  board  stated  it  "has  the 
opportunity  to  save  millions  of  lives".10  Once 
guidelines  are  established  to  avoid  possible  abuse, 
AHA  intends  to  offer  funding  in  the  future. 

The  temptation  of  the  benefits  of  new  rem- 
edies and  possible  cures  for  diseases  can  sway 
the  public  interest.  This  can  in  turn  influence  the 
lawmakers  into  more  positively  supporting  stem 
cell  research.  It  seems  that  when  someone  has  a 
personal  interest  in  an  issue,  such  as  a loved  one 
with  a chronic  illness,  other  issues  can  be  over- 
looked in  order  to  benefit.  For  example,  a con- 
gressman whose  daughter  is  diabetic  supports 
stem  cell  research  even  though  he  is  conserva- 
tive. This  lawmaker  knows  that  research  must 
be  done  in  order  to  possibly  find  a cure  for  his 
daughter.  With  his  personal  stake  in  the  issue, 
his  vote  is  swayed  toward  supporting  stem  cell 
research.  Many  individuals  act  in  this  way.  An- 
other example.  Senator  Arlen  Specter  became  a 
supporter  of  stem  cell  research  after  suffering 
from  a brain  tumor.39 

If  the  "most"  ethical  way  to  handle  research 
is  chosen,  people  are  more  prone  to  accept  it. 
However,  there  will  always  be  strong  opponents 
who  are  adamant  in  their  stand.  Congressman 
Jay  Dickey  stated,  "the  (federal)  ban  serves  a 
very  good  purpose  in  our  society  because  it  hon- 
ors the  sanctity  of  life."1 

ETHICS  ELSEWHERE 

As  stated  earlier,  Sweden  has  been  performing 
research  using  aborted  fetuses  for  over  10  years.22 


Germany  currently  has  the  strictest  laws  regard- 
ing human  embryo  use  in  research,  but  "the  gap 
between  the  extreme  positions  is  narrowing."40 
In  Japan,  the  Council  for  Science  and  Technol- 
ogy (CST)  published  a report  allowing  stem  cell 
research.  Embryos  less  than  2 weeks  old  will  be 
acquired  from  fertility  clinics,  and  the  fertility 
clinics  will  retain  all  information  on  donors.41  In 
August  2000,  the  British  government  lifted  its 
ban  on  the  cloning  of  human  beings  to  perform 
"therapeutic  cloning"  for  the  purpose  of  "creat- 
ing human  embryos  for  the  specialized  cells  that 
can  be  derived  from  them."42  Currently,  France 
does  not  allow  human  embryonic  research,  but 
debates  are  planned  later  this  year  to  discuss 
allowance  of  embryonic  use  for  stem  cell  re- 
search.43 

CONCLUSION 

Moral  and  ethical  decisions  arise  everyday,  and 
ethics  in  research  practices  is  an  important  and 
evolving  area.  A common  ground  must  be  met, 
such  as  clarification  to  the  public  of  exactly  what 
is  going  on  in  the  laboratories.  The  best  opinion 
the  public  can  have  is  an  educated  opinion. 
Many  hear  of  stem  cell  research,  but  do  not  know 
enough  about  the  subject  matter  to  voice  an  edu- 
cated opinion.  Many  people  base  their  decisions 
on  beliefs  and  culture.  Our  cultural  norms  dic- 
tate to  us  what  is  morally  right  versus  wrong. 
There  are  some  countries  who  are  moving  ahead 
of  the  United  States  because  of  our  conflicting 
viewpoints;  however,  many  countries  have  hesi- 
tated on  this  decision  as  have  we.  Supporting 
fetal-tissue  research  does  not  mean  support  of 
abortion.  It  does  not  mean  sacrificing  one's  moral 
standards  to  allow  disrespect  and  invasion  of 
human  embryos.  As  the  NBAC  summary  states, 
"We  are  hopeful  that  this  dialogue  will  foster 
public  understanding  about  the  relationships 
between  the  opportunities  that  biomedical  sci- 
ence offers  to  improve  human  welfare  and  the 
limits  set  by  important  ethical  obligations."5  The 
political  positions  of  the  2000  presidential  can- 
didates came  under  scrutiny  based  on  their  in- 
dividual stands  on  this  issue.  It  seems  that  the 


622  J La  State  Med  Soc  VOL  152  December  2000 


Health  Law  and  Biomedical  Ethics 


abortion  issue  is  being  tied  into  the  fetal-tissue 
research  issues  when  they  could  be  considered 
as  separate  entities.  It  seems  many  individuals 
are  having  trouble  distinguishing  the  two. 

The  resulting  opinion?  The  development  of 
penicillin  and  the  discovery  of  DNA,  along  with 
countless  other  breakthroughs,  have  changed  all 
of  our  lives  in  some  way.  These  discoveries  came 
through  scientific  research  which  many  people 
may  not  find  ethically  acceptable.  Laboratory 
animals  were  often  used,  which  offends  many 
animal  rights  activists.  However,  when  consid- 
ering the  outcome,  many  will  agree  that  the  dis- 
covery saves  far  more  lives  than  it  sacrificed. 
With  DNA  testing  of  microscopic  evidence,  we 
can  now  convict  murderers  who  once  walked 
free  because  their  crime  could  not  previously  be 
proven  and  set  free  others  who  are  innocent. 
Research  can  result  in  progress,  but  at  what  ethi- 
cal cost? 

ACKNOWLEDGEMENTS 

I would  like  to  thank  Joanne  Marier,  JD,  PT,  and 
Anne  Jordan,  EdD,  for  submitting  my  paper.  I 
would  also  like  to  thank  the  following  for  their 
assistance  in  editing  the  manuscript:  Elizabeth 
T H Fontham,  DrPH;  Patricia  Gauntlett  Beare, 
RN,  PhD;  and  Demetrius  Porche,  DNS. 

REFERENCES 

1.  Butler  D.  Breakthrough  stirs  US  embryo  debate. 
Nature  1998;396:104. 

2.  Lanza  RP.  Science  over  politics.  Science 
1999;283:1849-1850. 

3.  Vogel  G.  Stem  cells:  Wisconsin  to  distribute  embry- 
onic cell  lines.  Science  2000;287:948-949. 

4.  Beardsley  T.  Culturing  new  life:  stem  cells  lead  the 
way  to  a new  medical  paradigm  in  tissue  regenera- 
tion. Scientific  American  1998;11-12. 

5.  National  Bioethics  Advisory  Commission  (NBAC). 
Executive  Summary,  Ethical  Issues  in  Human  Stem 
Cell  Research.  Rockville,  Md;1999;  www.bioethics.gov. 

6.  Immortal  cells  spawn  ethical  concerns.  Science 
1998;282:2161. 

7.  Nelson  JL.  Ethics  & Embryos.  Forum  for  Applied  Re- 
search and  PubUc  Policy 2000;15:49-53. 

8.  Steghaus-Kovac  S.  Ethical  loophole  closing  up  for 
stem  cell  researchers.  Science  1999;286:31. 


9.  Vogel  G.  Can  old  cells  learn  new  tricks?  Science 
2000;287:1418-1419. 

1 0 . Associated  Press.  American  Heart  Association  endorses 
stem-cell  research.  Available  at:  www.cnn.com/2000/ 
HEALTH/ 06/27/ stemcell.research.ap/ index.htm. 

11.  Reuters.  Stem  cells  could  help  in  cancer,  spine  in- 
jury. Available  at:  www.cnn.com/2000/HEALTH/ 
04/10/  health,  stemcells  .reut  / index  .htm. 

12.  Towards  the  acceptance  of  embryo  stem-cell  thera- 
pies. Nature  1999;397:270. 

13.  Marshall  E.  Use  of  stem  cells  still  legally  murky,  but 
hearing  offers  hope.  Science  1998;282:1962-1963. 

14.  Vogel  G.  Capturing  the  promise  of  youth.  Science 
1999;286:2238-2239. 

15.  Sickle  Cell  Anemia:  stem-cell  transplant  successful. 
American  Health  Line  The  National  Journal  Group, 
Inc.;1999. 

16.  Gearhart  J.  New  potential  for  human  embryonic 
stem  cells.  Science  1998;282: 10611-10612. 

17.  Wadman  M.  Embryonic  stem-cell  research  exempt 
from  ban,  NIH  is  told.  Nature  1999;397:185-186. 

18.  Lab-Grown  Stem  Cells  as  Effective  as  Donated  Cells 
in  Breast  Cancer  Study.  Medical  Industry  Today  Medi- 
cal Data  International,  Inc.;2000. 

19.  Birmingham  K.  University  stem  cells  for  sale.  Na- 
ture Medicine  2000;6:23 7. 

20.  Marshall  E.  Ruling  may  free  NIH  to  fund  stem  cell 
studies.  Science  1999;283:466-467. 

21 . Young  FE.  A time  for  restraint.  Science  2000;287:1424. 

22.  Barinaga  M.  Fetal  neuron  grafts  pave  the  way  for 
stem  cell  therapies.  Science  2000;287:1421-1422. 

23.  Ayers  T.  Stem  cell  research  focus  of  congressional 
briefing.  AAAS  2000;288:1442. 

24.  National  Institutes  of  Health  (NIH).  Fact  sheet  on  hu- 
man pluripotent  stem  cell  research  guidelines.  Avail- 
able at:  www.nih.gov/  news/  stemcell/factsheet.htm. 

25 . NIH.  National  Institutes  of  Health  guidelines  for  research 
using  human  pluripotent  stem  cells.  Available  at: 
www.nih.gov /news/ stemcell/stemcell  guidelines.htm. 

26.  Renault  B.  Editorial:  Stem  cells  - why  wait?  Nature 
Med  2000;6:231. 

27.  Stem  Cell  Research  Act  of  2000.  S 2015  - 106th  Con- 
gress 2nd  Session.  Congressional  Information  Ser- 
vice, Inc.  (CIS)  Bill  Tracking  Report.  Congressional 
Universe  documents  2000. 

28.  No  Title.  HRS  414  - 106th  Congress  2nd  Session. 
Congressional  Information  Service,  Inc.  (CIS)  Bill 
Tracking  Report.  Congressional  Universe  docu- 
ments 2000. 

29 . O'Connor  E.  Subcommittee  hears  testimony  on  stem 
cell  research.  Available  at:  www. cnn.com /2000/ 
HEALTH/09/14/ stemcell.hearing/ index.html. 

30 . Do  No  Harm:  The  Coalition  of  Americans  for  Research 
Ethics  (CARE).  Stem  Cell  Report:  September/ Octo- 


J La  State  Med  Soc  VOL  1 52  December  2000  623 


Health  Law  and  Biomedical  Ethics 


ber  2000  Advances  in  alternatives  to  embryonic  stem 
cell  research.  Available  at:  www.stemcellresearch.org/ 
scr-sep2000.htm. 

31.  Do  No  Harm:  CARE.  Stem  Cell  Report:  July /Au- 
gust 2000  Advances  in  Alternatives  to  Embryonic 
Stem  Cell  Research.  Available  at: 
www.stemcellresearch.org  / scr-j  ul2000 .htm . 

32.  Do  No  Harm:  CARE.  Stem  Cell  Report:  June  2000 
Advances  in  Alternatives  to  Embryonic  Stem  Cell 
Research.  Available  at:  www.stemcellresearch.org/ 
scr-june2000.htm. 

33.  Lenoir  N.  Science's  Letters:  historical  views  on  the 
human  embryo.  Science  2000;288:439-440. 

34.  Marshall  E.  Embryologists  dismayed  by  sanctions 
against  geneticist.  Science  1997;275:472. 

35.  Marshall  E.  Fetal  Tissue  Research:  antiabortion 
groups  target  neuroscience  study  at  Nebraska.  Sci- 
ence 2000;287:202-203. 

36.  Wadman  M.  Charity  cools  on  stem  cells  after  boy- 
cott by  Catholics.  Nature  1999;400;  5. 

37.  Stem-cell  research  and  the  US  Congress.  Nature 
2000;405:1. 

38.  National  Catholic  Bioethics  Center  (NCBC).  De- 
stroying human  embryos  for  research.  Ethics  & 
Medics  Boston,  Mass;  2000.  Available  at: 
www.ethicsandmedics.com/ 0003-1. html. 

39.  Fields  H.  Senate  decides  to  withhold  support  for 
stem  cell  research.  Biotechnology  Newswatch  The 
McGraw-Hill  Companies,  Inc;  1999. 

40.  Schiermeier  Q.  Germany  edges  towards  stem-cell 
accord.  Nature  2000;405:499. 

41.  Triendl  R.  Japan  to  permit  stem  cell  research.  Na- 
ture Med  2000;6:239. 

42 . Kahn  J.  Falling  behind  in  the  stem  cell  race?  Available  at: 
www.cnn.com/ 2000 /HEALTH/08/ 22/ethics.matters. 

43.  McKay  R.  Stem  cells  - hype  and  hope.  Nature 
2000;406:361-364. 


Ms  Trepagnier  holds  a Bachelor  of  Arts  degree  in  Psy- 
chology She  is  a December 2000  Candida  te  for  a 
Master  of  Science  in  Health  Care  Managemen  t. 
Both  degrees  are  from  the  University  of  New  Orleans. 


624  J La  State  Med  Soc  VOL  152  December  2000 


Health  Law  and  Biomedical  Ethics 


In  Vitro  Fertilization: 
A Right  or  A Privilege? 


Brooke  Lambard  Kyle,  MD 


Infertility  is  a common  medical  problem  affecting  millions  of  couples  worldwide.  As  new 
and  more  effective  treatments  arise,  a host  of  ethical  issues  are  generated.  Is  reproduction  a 
fundamental  right,  or  a luxury?  Is  it  in  the  best  interests  of  society  to  guarantee  reproductive 
abilities  for  all  of  its  members?  Specifically,  should  insurance  companies  be  compelled  to 
pay  for  all  expensive  infertility  therapies  (such  as  in  vitro  fertilization),  especially  in  light 
of  global  over-population  concerns?  This  paper  addresses  these  issues,  and  discusses  other 
ethical  considerations  generated  by  infertility  treatments. 


Infertility  is  a common  problem  affecting  ap- 
proximately 12%  of  couples  worldwide.1 
That  is,  one  out  of  nine  married  couples 
cannot  conceive  after  1 year  of  unprotected, 
unmedicated  intercourse.  This  staggering  sta- 
tistic has  opened  a Pandora's  box  of  ethical,  le- 
gal, and  monetary  issues  regarding  forms  of 
treatment,  especially  in  vitro  fertilization  (IVF). 
In  the  1980s,  infertility  treatment  boomed  fol- 
lowing the  birth  of  baby  Louise  Brown,  the  first 
"test  tube  baby".  Other  options,  ie,  adoption, 
could  be  considered;  however,  two  million  white 
American  couples  seek  22,000  Caucasian  babies 
yearly  (other  races'  statistics  were  not  delin- 
eated).2 Clearly,  there  are  not  enough  babies  to 
go  around,  especially  with  many  states'  laws 
against  adoption  across  racial  lines.  With  the  de- 


lay of  gestation  by  women  in  the  past  40  years 
as  they  begin  careers,  infertility  and  birth  defects 
increase  exponentially,  resulting  in  more  still- 
births and  chromosomal  abnormalities.  For  ex- 
ample, a couple  I saw  once  for  fertility  counsel- 
ing: the  potential  mother  had  a previous  ectopic 
pregnancy  for  which  both  fallopian  tubes  were 
supposedly  removed,  rendering  her  sterile  and 
childless  at  22.  She  had  met  and  married  a quad- 
riplegic veteran  6 years  prior  to  our  visit.  The 
couple  would  have  been  good  candidates  for  IVF 
with  zygote  or  gamete  placement  in  the  uterus. 
As  I sat  listening  to  their  heart-wrenching  story, 
they  informed  me  they  were  seeking  help  in  the 
Louisiana  State  University  system  because  their 
insurance  plan  refused  to  pay  for  such  treat- 
ments. 


J La  State  Med  Soc  VOL  152  December  2000  625 


Health  Law  and  Biomedical  Ethics 


More  and  more  couples  seek  infertility  treat- 
ments and  ask  their  insurance  to  pay.  Should 
insurance  foot  the  bill  for  such  expensive  treat- 
ments? Should  infertility  be  a part  of  the  Ameri- 
cans with  Disabilities  Act?  There  are  many  op- 
tions to  consider;  I believe  that  insurance  should 
be  responsible  for  less  expensive,  first  line  thera- 
pies and  not  responsible  for  the  more  advanced 
therapies  like  GIFT  and  ZIFT  (Gamete /Zygote 
Intrafallopian  Transfer). 

When  a couple  seeks  an  infertility  workup, 
it  begins  with  thorough  evaluation  of  both  part- 
ners. Statistically,  35%  of  infertility  is  due  to  the 
male  partner,  while  25%  is  due  to  a pelvic  factor 
(ie,  blockage  of  fallopian  tubes),  20%  is  due  to 
ovulatory  factors  (ie,  anovulation),  and  10%  is 
due  to  a cervical  factor  (ie,  cervical  mucus  being 
impenetrable  by  sperm)1.  First,  the  histories  and 
physical  examinations  of  both  partners  are  ana- 
lyzed, looking  for  clues  to  the  etiology  of  infer- 
tility. Second,  a semen  analysis  is  performed  and 
ovulation  is  documented  through  basal  body 
temperature  measurements,  serum  progester- 
one, or  endometrial  (uterine)  biopsy.  The  post- 
coital  tests  can  then  be  done  to  note  the  sperm/ 
cervical  mucus  interaction.  An  evaluation  of  tu- 
bal patency  can  also  be  performed  by  hystero- 
salpingography.1 

What  can  be  done  for  causes  of  infertility?  If 
the  semen  analysis  is  found  to  be  abnormal,  a 
urologist  may  recommend  treatment  with  hor- 
mones to  increase  sperm  number  and  quality. 
Female  pelvic  factors  may  be  remedied  with  tu- 
bal microsurgery  to  repair  the  deficit  in  the  tubes. 
This  is  15%  to  70%  successful.  Uterine  causes 
such  as  adhesions  (Asherman  syndrome)  can  be 
repaired.  Endometriosis,  the  presence  of  uterine 
tissue  outside  the  uterus  on  the  ovaries  or  pel- 
vic wall,  can  be  treated  medically  with  Danazol 
(an  androgen),  oral  contraceptives,  other  hor- 
mones (GnRH  analogues),  or  can  be 
laparoscopically  electrocoagulated.  Ovulatory 
disorders  can  be  treated  medically  with  Clomi- 
phene,  human  menopausal  gonadotropin,  or 
gonadotropin  releasing  hormone  (GnRH)  to  "in- 
duce" ovulation.1 

An  egg  may  be  removed  from  the  ovary  once 


primed  through  vaginally-guided  ultrasound 
and  needle  suction.  The  egg  is  then  cultured  on 
a petri  dish;  sperm  is  added  6-12  hours  later.  The 
natural  processes  of  fertilization  take  place  and 
the  zygote  is  allowed  to  rest  and  divide  for  24 
hours.  The  embryo  is  then  placed  through  a di- 
lated cervix  into  the  uterus,  where  it  hopefully 
will  implant.  GIFT  (Gamete  Intra  Fallopian 
Transfer)  is  a procedure  where  the  sperm  and 
egg  are  both  transferred  through  needles  to  the 
fallopian  tubes,  where  fertilization  would  nor- 
mally take  place  (23%  success  rate).  ZIFT  (Zy- 
gote Intra  Fallopian  Transfer)  places  the  zygote 
(a  fertilized  egg,  dividing)  to  the  oviduct  (17% 
successful).3  These  techniques  are  generally  safe 
for  mother  and  embryo.  There  is  a mild  increase 
in  the  rates  of  spontaneous  abortion  (miscar- 
riage) with  multiple  gestations  as  well  as  an  in- 
creased risk  of  ectopic  pregnancy  after  IVF  (due 
to  surgical  correction  of  tubes  or  GIFT/ZIFT  as 
adhesions  form,  possibly  blocking  the  tubes).3 

In  1977,  baby  Louise  Brown  was  the  first  child 
to  be  conceived  in  vitro.  Lesley  Brown,  a 
cheesemaker  in  England,  and  her  husband  John 
Brown,  a truck  driver,  had  problems  conceiving 
a child  and  went  to  obstetrician  Patrick  Steptoe. 
With  the  help  of  physiologist  Robert  Edwards, 
the  eggs  harvested  from  Mrs  Brown  were  cultured 
with  Mr  Brown's  semen.  The  zygote  was  then 
reinserted  through  Mrs  Brown's  cervix.  On  June 
25, 1978,  Louise  Joy  Brown  was  bom,  weighing  5 
pounds,  12  ounces  (somewhat  growth  restricted, 
but  the  gestational  age  was  not  given).  Flamboy- 
ant and  sensational  news  stories  ensued,  calling 
Louise  a "test  tube  baby"  conceived  without 
sperm  or  eggs  (obviously  not  the  case.)  In  fact, 
the  story  was  sold  to  the  National  Enquirer jirst 
for  the  sum  of  $600,000.3  A huge  ethical  debate 
followed  as  the  world  ushered  in  the  age  of  ad- 
vanced reproductive  technology. 

Nobel  Prize  winner  James  Watson  (of  Watson 
and  Crick  DNA  fame)  predicted  dangerous 
events  would  follow  the  birth  of  baby  Louise. 
Many  people  feared  the  creation  of  a superhu- 
man race  through  genetic  technology  and  the 
abandonment  of  natural  conception.  Ethically, 
Christian  theologists  were  divided  upon  the  is- 


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Health  Law  and  Biomedical  Ethics 


sue  of  IVF.  The  Vatican  condemned  IVF  in  1978 
equating  it  with  "domination"  and  "manipula- 
tion of  nature.2  One  bishop  said,  "The  fact  that 
science  now  has  the  ability  to  alter  this  process 
significantly  does  not  mean  that,  morally  speak- 
ing, it  has  the  right  to  do  so."4  Many  Christians 
felt  that  infertility  was  God's  way  of  punishing 
those  for  past  sins,  a physiologic  reality,  as  sexu- 
ally transmitted  diseases  were  associated  with 
pelvic  inflammatory  disease,  which  could  cre- 
ate tubal  blockage.  The  Vatican  continues  to  hold 
that  intercourse  is  required  for  moral  conception. 
Theologian  Joseph  Fletcher  defended  IVF  and 
believed  its  use  should  be  considered  on  an  in- 
dividual basis,  whereas  theologian  Paul  Ramsey 
believed  genetic  manipulation  was  wrong  be- 
cause the  zygote  could  not  give  his  consent.2 
Christianity  is  divided  on  the  ethical  issues  re- 
garding IVF. 

Many  ethical  issues  arise  over  advanced  re- 
productive technologies.  Many  could  be  dis- 
cussed, however  this  paper  will  address  only 
those  regarding  IVF,  not  surrogacy.  Philosopher 
Michael  Baynes  brought  up  the  idea  of  "irratio- 
nal desires",  that  people  are  irrational  about  then- 
desires  to  raise  their  own  children  instead  of  those 
from  adoption2.  He  also  felt  that  public  policy 
should  not  be  based  upon  irrational  desires,  thus 
IVF  should  be  banned.  Concerns  of  this  ethical 
perspective  include  the  strong  natural,  evo- 
lutional, and  emotional  ties  a couple  may  feel  as 
they  try  to  procreate  - something  grounded  so 
surely  in  the  survival  of  our  race  could  not  be 
irrational.  Also,  with  the  incongruity  between  the 
number  of  adoptive  couples  and  babies — clearly, 
there  is  a shortage  of  babies,  especially  Cauca- 
sian babies.2  Even  with  more  couples  seeking 
children  abroad  and  trying  fruitlessly  to  adopt 
across  racial  lines,  there  are  many  unsatisfied 
couples  left  childless. 

Ethically,  one  wonders  whether  harm  would 
ensue  to  the  baby.  In  the  late  1970s,  people  were 
unsure  what  baby  Louise  would  look  like,  a de- 
formation or  even  "Cyclops?"  After  the  on- 
slaught on  reproductive  therapies,  it  is  now  clear 
that  healthy  babies  are  the  norm  for  IVF,  with 
only  a mild  natural  risk  of  growth  restriction 


with  multiple  gestations  and  a mild  increase  in 
the  rate  of  miscarriages.  One  also  wonders 
whether  possible  children  could  be  harmed  by 
IVF?  This  is  resolved  by  the  Paradox  of  Exist- 
ence, that  it  never  seems  worse  to  live  with  a 
"low  quality  of  life"  than  not  to  exist  at  all.2 

The  status  of  the  embryo  is  an  ethical  and 
legal  concern.  If  six  pre-embryos  (ie,  zygotes)  are 
implanted,  only  one  or  two  can  usually  be  raised 
gestationally  to  be  healthy  children.  Do  you  kill 
the  others?  Which  do  you  choose?  One  can  have 
six  children,  as  was  demonstrated  recently  by 
the  media,  but  it  may  be  deleterious  to  all,  born 
smaller,  younger,  and  with  more  complications. 
The  solution  that  seems  to  be  obvious  in  this  case 
is  prevention:  implanting  only  one  or  two  em- 
bryos at  a time  and  using  the  drugs  that  induce 
ovulation  sparingly.  The  American  College  of 
Obstetritians  and  Gynecologists  position  on  this 
issue  is  as  mentioned  and  to  educate  the  par- 
ents on  such  implications  and  follow  their  di- 
rectives about  what  therapy  to  use.5  Ultimately, 
the  decision  lies  with  the  parents.  In  1981,  Mario 
and  Elsa  Rios,  a wealthy  American  couple  with 
embryos  stored  in  Australia,  were  killed  in  a 
plane  crash.  Ethics  committees  and  the  Austra- 
lian parliament  wondered  if  (a)  the  embryos 
could  be  destroyed,  (b)  could  they  be  implanted 
in  surrogate  moms  for  inheritance,  and  (c) 
should  the  anonymous  sperm  donor  from  the 
zygote  be  contacted?  The  committee  recom- 
mended destruction  of  the  pre-embryos  and 
equated  it  with  removal  of  life  support  from  a 
terminal  patient.2  The  issue  of  an  embryo  as  a 
person,  sex  selection,  surrogacy,  and  other  ge- 
netic issues  will  be  left  to  other  discussions,  as 
this  is  not  an  exhaustive  paper  on  these  issues. 

One  also  considers  harm  to  society  an  ethi- 
cal issue  in  advanced  reproductive  technologies. 
People  do  fear  the  creation  of  a "superhuman" 
race;  however,  such  same  technology  would  be 
used  to  eradicate  genetic  disease  like  cystic  fi- 
brosis and  Down's  syndrome.  Another  harm  to 
society  is  due  to  the  population  increase  from 
IVF.  Although  the  increase  would  be  minimal, 
with  the  world's  population  nearing  carrying 
capacity  of  the  earth,  all  rational  efforts  on  cur- 


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Health  Law  and  Biomedical  Ethics 


tailing  the  growth  rate  should  be  implemented. 
The  population  reached  6 billion  people  in  Sep- 
tember 1999  from  2 billion  in  1930.  It  is  expected 
to  double  by  2050. 6 Overpopulation  causes  a 
myriad  of  problems  such  as  poverty,  disease, 
food  shortage,  exacerbation  of  the  Greenhouse 
Effect  from  overproduction  of  carbon  dioxide, 
wasting  of  the  earth's  natural  resources,  and  so 
on.  22%  of  our  fisheries  are  depleted  and  44% 
are  at  the  limits  of  exploitation.  The  overall  popu- 
lation growth  rate  is  2.1%  per  year,  fastest  in 
Africa,  Latin  America,  and  Asia.  In  many  coun- 
tries, the  birth  rate  is  high,  and  due  to  improv- 
ing medical  care  the  death  rate  is  declining.  The 
US  growth  rate  is  0.7%.6 

China,  since  1979,  has  had  a goal  of  limiting 
population  to  1.2  billion  by  the  year  2000.  The 
government  limits  the  number  of  children  to  1, 
in  rare  cases  2,  and  has  mandatory  intrauterine 
device  placement  after  childbearing.  It  is  con- 
sidered a crime  to  remove  the  device.  Some  prov- 
inces even  require  sterilization;  a woman  is  pun- 
ished for  refusing  to  terminate  unapproved  preg- 
nancies. In  1983,  there  were  14.4  million  abor- 
tions performed;  there  were  19  million  live  births 
that  year.6  This  is  an  extreme  model  of  popula- 
tion control  that  is  not  advocated  in  the  United 
States.  However,  China  does  see  the  need  for 
population  control,  even  if  its  means  seem  bar- 
baric and  unethical.  The  population  of  China 
now  at  year  2000  is  1.3  billion.  The  Cairo  UN 
Conference  on  population  in  1994  recommended 
universal  access  to  family  planning  and  repro- 
ductive health  programs,  an  increase  in  the  sta- 
tus of  women,  an  increase  in  the  role  men  play 
in  supporting  pregnancies,  and  education  of  all. 
These  methods  seem  much  more  reasonable  and 
have  been  adopted  by  many  countries.6  This 
utilitarian  argument  on  the  ethicality  of  IVF  may 
seem  overreaching,  but  in  an  era  of  controlled 
costs,  it  seems  unreasonable  to  have  insurance 
pay  for  extended  fertility  treatments  to  increase 
the  population. 

There  are  a number  of  laws  and  cases  regard- 
ing reproductive  therapies.  I will  only  glaze 
through  ones  pertinent  to  IVF  and  not  surrogacy, 
etc.  The  Uniform  Parentage  Act  of  1973  stated 


that  law  treats  the  husband  of  the  wife  receiving 
artificial  insemination  with  donor  sperm  as  if  he 
were  the  father  of  such  offspring.  The  Uniform 
Status  of  Children  of  Assisted  Conception  Act 
of  1988  regards  children  of  in  vitro  fertilization 
as  stated  in  the  Uniform  Parentage  Act.  It  states 
that  the  donor  is  not  the  parent;  the  individual 
who  dies  before  implantation  is  also  not  the  par- 
ent. It  has  not  been  adopted  as  uniformly  as  the 
Uniform  Parentage  Act.7  The  Sperm  Donor  Act 
relinquishes  the  donor  of  the  semen  from  paren- 
tal responsibilities  of  child-rearing. 

Davis  v.  Davis , in  the  Supreme  Court  of  Ten- 
nessee in  1992,  regarded  the  custody  of  seven 
previously  frozen  embryos  which  the  divorcing 
husband  wanted  thrown  away  and  which  the 
divorcing  wife  wanted  to  give  to  other  infertile 
couples.  The  question  of  embryos  as  person  or 
property  arose:  The  American  Fertility  Society 
proposed  three  options:  (a)  embryo  as  person 
only,  (b)  embryo  as  property  only,  as  any  other 
human  tissue,  and  (c)  a median  between  choice 
(a)  and  (b).  The  court  held  for  position  (c)  and 
considered  prior  agreements  between  the  couple 
to  be  binding  and  the  embryos  were  destroyed." 
Kass  v Kass,  1998,  ruled  that  both  parties  must 
agree  to  implantation  of  the  stored  embryo  as 
Mrs  Kass  wanted  the  embryos  implanted  in  her 
uterus  after  the  divorce  from  her  husband.8 

ADA  legislation  includes  Bielicki  v.  City  of 
Chicago,  1998,  where  Mrs  Bielicki  filed  under 
ADA  Title  One  and  the  Pregnancy  Discrimina- 
tion Act  to  be  covered  for  fertility  treatment  un- 
der her  employment  health  plan  as  men  were. 
They  included  it  in  ADA  because  infertility  is  a 
physical  impairment,  affects  a major  life  activ- 
ity (reproduction),  and  reproduction  is  substan- 
tially limited  by  infertility.9  The  ADA  and  its  in- 
clusion of  infertility  is  a controversial  topic  dis- 
cussed later. 

How  does  one  manage  the  overwhelming 
costs  of  health  care  and  the  needs  of  infertile 
couples?  First,  one  could  say  fertility  is  a right 
and  insurance  should  pay;  infertility  should  be 
covered  under  the  ADA.  Second,  one  could  say 
fertility  is  entirely  a privilege  and  insurance 
should  not  pay  for  IVF;  infertility  should  not  be 


628  J La  State  Med  Soc  VOL  1 52  December  2000 


Health  Law  and  Biomedical  Ethics 


covered  under  the  ADA.  Third,  there  could  be 
middle  ground:  there  is  a spectrum  of  infertility 
treatment.  After  cost  analysis,  it  seems  that  mini- 
mal medical  treatments  (one  to  two  rounds  of 
ovulation  induction  agents,  artificial  insemina- 
tion, basic  labwork,  minimal  laparoscopic  surgery 
to  revise  tubes)  are  usually  monetarily  reasonable 
and  could  be  of  great  benefit  to  infertile  couples. 
The  more  costly  treatments  (GIFT,  ZIFT,  etc.) 
would  hence  be  left  uncovered  by  insurance. 

Of  all  choices,  the  third  is  the  most  logical. 
The  first,  total  payment  of  infertility  workup, 
would  be  a large  step  for  insurance  to  cover  - 
fertility  treatments  are  costly.  Calling  infertility 
a right  is  dangerous  ground;  it  may  induce  the 
"slippery  slope  effect"  and  other  conditions 
would  soon  be  entitled  under  the  ADA.  In  the 
Bielicki  case,  I do  not  believe  that  reproduction 
is  a major  life  activity  as  an  individual  (note:  the 
case  was  also  filed  under  Title  One,  coverage 
under  employment  and  was  not  far-reaching  in 
its  effects.)  On  an  individual  level,  it  is  not  nec- 
essary for  one  to  reproduce  to  survive.  As  a 
population,  it  must  reproduce  to  survive.  With 
population  growth  rate  as  large  as  it  is,  there  is 
no  need  to  go  to  extensive  means  to  facilitate 
reproduction.  The  second  option,  no  coverage 
for  fertility  treatments  at  all,  leaves  many  people 
"high  and  dry"  whose  problems  could  easily  be 
solved  with  minimal  effort.  What  I call  the 
"Goldilocks  third  option,"  is  "just  right."  It  bal- 
ances one's  emotional  and  human  wants  for  pro- 
creation with  controlling  costs  of  health  care  and 
limiting  of  funds  for  taking  care  of  the  popula- 
tion we  have,  not  adding  to  the  problem.  Those 
whose  problems  are  easily  fixed  are  satisfied,  as 
are  the  people  footing  the  bill.  For  those  who 
prove  completely  infertile,  I propose  that  the 
highways  of  intercountry  adoption  be  broad- 
ened to  take  away  burden  from  developing  na- 
tions. 

Opposition  to  the  Goldilocks  option  could 
include  a few  issues.  Allowing  extensive  fertil- 
ity treatment  to  be  paid  for  by  wealthy  individu- 
als would  be  performing  such  treatment  on  only 
the  upper  class  that  could  afford  it.  This 
"classism"  is  an  inherent  flaw  in  the  US  system 


of  health  care.  People  with  money  get  insurance; 
those  without  (ie,  40  million  US  citizens  now) 
do  not.  Another  argument  would  be  the 
miniscule  amount  of  population  added  by  IVF. 
This  is  true,  but  when  one  considers  population 
concerns  with  health  care  costs,  the  benefits  of 
redistribution  of  the  health  care  dollar  outweigh 
the  risks  of  the  current  system. 

Infertility  treatment  is  truly  in  its  infancy. 
There  will  be  many  new  treatments  available 
through  genetic  advances  made  in  the  next  50 
years.  This  will  be  a battle  fought  on  many 
grounds.  My  proposition  allows  the  right  mix 
of  cost  containment,  population  control,  and 
infertility  workup  to  please  many. 

REFERENCES 

1 . ACOG.  Infertility.  In:  2000  Compendium  of  Selected 
Publications.  Washington,  DC:  ACOG;  2000. 
[Technical  Bulletin  No.  125.] 

2 . Pence  G . Classic  Cases  in  Medical  Ethics.  New  York: 
McGraw-Hill;  1990:67-85. 

3.  DroegemullerW,  Stenchever  M,  Mishell  D,  et  al. 
Comprehensive  Gynecology,  2nd  edition.  St  Louis: 
Mosby-Year  Book;  1992:1139. 

4.  Vecsey  G.  Religious  leaders  differ  on  implant. 

New  York  Times  July  27,1978;  A16. 

5.  ACOG.  Nonselective  embryo  reduction.  In:  2000 
Compendium  of  Selected  Publications.  Washington, 
DC:  ACOG;  2000.  [Committee  Opinion  No.  215.] 

6.  Bryant  P.  Human  Population  Growth.  1999:  l-12.Avail- 
able  at:  http://www.darwin.bio.uci.edu. 

7.  Furrow  B,  Greaney  T,  Johnson  S,  et  al.  Health  Law 
Cases , Materials ; and  Problems,  3rd  edition.  St  Paul, 
Minn:  West  Publishing;  1997:950-961. 

8.  Vorzimer,  Masseqmer,  Ecoff.  Legal  update:  recent 
cases  and  legislation.  J Asst Repro  Law  1999;1. 
Available  at  http://www.donorlaw.com/jarl.htm 

9.  Vorzimer,  Massemer,  Ecoff.  Legal  update:  recent 
cases  and  legislation.  J Asst  Repro  Law  1999;2.  Avail- 
able at  http://www.donorlaw.com/jarl.htm. 


Dr  Kyle  is  a resident  in  Obstetrics  and  Gynecology  at 
Louisiana  State  University  Health  Sciences  Center 
in  New  Orleans,  Louisiana. 


J La  State  Med  Soc  VOL  152  December  2000  629 


Health  Law  and  Biomedical  Ethics 


Domestic  Violence  in  Medical  Practice: 

A New  Approach  for  Louisiana  Physicians 


Nancy  Kang,  BA 


This  article  describes  the  role  of  the  physician  in  reporting  domestic  violence,  the  current 
situation  in  Louisiana,  and  how  California  addressed  this  problem.  The  author  advocates  a 
statewide  comprehensive  domestic  violence  education  program  for  medical  students,  resi- 
dents, and  physicians.  She  describes  a program  which  would  focus  on  awareness,  screening, 
diagnosis,  and  referral. 


Domestic  violence  is  defined  as  the  oc- 
currence of  one  or  more  of  the  follow 
ing  acts  between  family  and  household 
members,  or  between  partners  of  a substantive 
dating  relationship:  attempting  to  cause  or  caus- 
ing physical  harm,  placing  another  in  fear  of  im- 
minent physical  harm,  causing  another  to  invol- 
untarily engage  in  sexual  relations  by  force, 
threat,  or  duress.1 

The  American  Medical  Association  calls  do- 
mestic violence  a " silent  violent  epidemic"  and 
estimates  that  1 in  3 women  will  be  assaulted  by 
a domestic  partner  in  her  lifetime.2  Domestic  vio- 
lence is  underestimated;  victims  do  not  report 
to  authorities  due  to  social  stigma  and  biases  and 
fear  of  retaliation  by  the  abuser.  Physicians  hold 
a unique  position  in  helping  these  situations  be- 
cause they  are  often  the  only  professionals  who 


have  regular  contact  with  victims.  Women  who 
are  assaulted  or  abused  seldom  report  attacks 
to  police,  but  most  see  their  doctor  regularly.2 
Doctors  have  an  ethical  duty  to  help  their  pa- 
tients in  domestic  violence  situations  but  are 
forced  to  balance  beneficence,  autonomy,  and 
confidentiality  with  their  patients.  Physicians 
also  need  to  protect  themselves  from  breech  of 
the  doctor /patient  relationship  while  helping 
patients  to  their  fullest  abilities.  The  focus  of  this 
proposal  is  to  suggest  guidelines  for  domestic 
violence  reporting  laws  and  present  an  educa- 
tion program  for  Louisiana  physicians  that  may 
help  them  identify,  treat,  and  refer  victims  of 
domestic  violence. 

Currently  there  exists  no  law  in  Louisiana 
establishing  domestic  violence  reporting  laws 
for  physicians.  However,  a reporting  law  for 


630  J La  State  Med  Soc  VOL  1 52  December  2000 


Health  Law  and  Biomedical  Ethics 


child  abuse  does  exist  in  this  state  and  provides 
a template  for  a possible  law  concerning  domes- 
tic violence.  The  child  abuse  reporting  law  de- 
fines mandatory  guidelines  for  reporting  child 
physical  abuse,  mental  abuse,  or  neglect.  Fail- 
ure to  report  when  reason  to  suspect  exists,  or 
filing  a report  known  to  be  false,  subjects  the 
reporter  to  criminal  prosecution.  Similar  guide- 
lines could  be  written  concerning  reports  of  do- 
mestic violence.  The  defined  reporting  proce- 
dures in  the  child  abuse  law  are  very  important. 
If  procedures  for  domestic  violence  reporting  are 
codified,  physicians  can  more  easily  report  oc- 
currences with  confidence  of  protection  under 
the  law.  For  example,  a report  by  a physician  of 
domestic  abuse  would  include  the  following 
information  if  known:  the  nature,  extent,  and 
cause  of  injury,  including  any  previously  known 
or  suspected  abuse;  names  of  others  in  the  house- 
hold possibly  exposed  to  similar  abuse;  and  how 
this  occurrence  came  to  the  reporter's  attention. 
A codified  procedure  also  prevents  the  report- 
ing of  any  unnecessary  or  damaging  informa- 
tion by  the  reporter.  A domestic  violence  report- 
ing law,  like  the  child  abuse  reporting  law, 
should  provide  immunity  of  the  reporter  from 
any  civil  or  criminal  liability. 

A law  on  domestic  violence  reporting,  how- 
ever, may  not  be  the  best  route  for  reducing  vio- 
lent acts,  helping  those  abused,  or  raising  aware- 
ness. There  are  several  reasons  that  support  this 
viewpoint.  In  child  abuse,  the  victim  may  have 
no  means  to  seek  help.  Parents  might  refuse  to 
admit  abuse  or  perpetrate  the  abuse  themselves. 
In  this  situation,  the  authority  of  the  government 
must  step  in.  Victims  of  domestic  violence  are 
not  children  and  have  the  autonomy  and  ability 
to  report  their  abusers  to  the  police.  Laws  may 
infringe  on  their  freedoms.  Fueled  by  the  death 
of  Nicole  Brown  Simpson,  California  enacted  a 
domestic  violence  reporting  law,  and  the  effects 
of  that  law  are  now  coming  under  much  criti- 
cism and  debate.  These  effects  bring  into  ques- 
tion the  efficacy  of  such  a reporting  law  for  Loui- 
siana. 

California  physicians  are  required  to  report 
to  police  all  patients  who  are  suspected  to  be 


victims  of  domestic  violence.  Two  years  after  the 
implementation  of  California's  domestic  vio- 
lence reporting  law,  statistics  show  that  report- 
ing of  domestic  violence  by  medical  personnel 
did  not  increase.  Fewer  victims  sought  medical 
care  for  fear  their  partners  would  be  arrested. 
Physician  ignorance  and  noncompliance  also  led 
to  the  ineffectiveness  of  the  new  law.3  Results 
from  a focus  group  of  abused  women  of  diverse 
backgrounds  found  four  themes  that  led  to  the 
abused  not  seeking  treatment  under  the  law:  (1) 
fear  of  retaliation  by  the  abuser,  (2)  fear  of  fam- 
ily separation,  (3)  mistrust  of  the  legal  system, 
and  (4)  preference  of  confidentially  and  au- 
tonomy in  the  patient-health  professional  rela- 
tionship.4 "Mandatory  reporting  may  pose  a 
threat  to  the  safety  and  well-being  of  abused 
women  and  may  create  barriers  to  their  seeking 
help  and  communicating  with  health  care  pro- 
fessionals about  domestic  violence."  4 Evidence 
of  the  non-efficacy  of  California's  law  raises 
questions  as  to  the  beneficence  of  a law.  Perhaps 
a law  in  Louisiana  would  do  more  harm  than 
good.  Fewer  victims  would  seek  treatment;  the 
only  venue  for  confidential  treatment  would  be 
cut  off.  Physicians  would  be  forced  to  report  re- 
gardless of  possible  danger  to  the  physician,  the 
patient,  and  the  patient's  family.  Four  million 
women  a year  would  remain  victims  of  domes- 
tic violence.  What  should  be  done? 

Perhaps  a more  effective  way  to  help  pre- 
vent domestic  violence,  promote  awareness,  and 
increase  aid  and  support  from  the  physician  is 
to  develop  a statewide  comprehensive  domes- 
tic violence  education  program  for  medical  stu- 
dents, residents,  and  physicians.  Education 
should  focus  on  awareness,  screening,  diagno- 
sis, and  referral.  The  program  also  should  touch 
on  legal  issues  for  the  physician  and  for  the  pa- 
tient. The  program  should  be  accessible  to  all 
physicians,  but  particularly  target  those  in  gen- 
eralist specialties  (Obstetrics /Gynecology,  Fam- 
ily Medicine,  etc.)  and  Emergency  Medicine, 
since  many  abuse  victims  present  in  the  emer- 
gency room. 

The  new  domestic  violence  education  pro- 
gram can  be  taught  as  classes  in  medical  schools 


J La  State  Med  Soc  VOL  152  December  2000  631 


Health  Law  and  Biomedical  Ethics 


and  residency  programs  in  the  state,  possibly  as 
a mandatory  course  requirement.  Classes  need 
to  involve  clinical  cases  and  practical  sugges- 
tions for  students.  "Despite  the  increase  in  num- 
ber of  medical  schools  reporting  curriculum  in 
family  violence,  there  does  not  appear  to  be  in- 
creased attention  to  this  problem,  at  least  as 
measured  by  time  devoted  to  teaching."1  Per- 
haps cases  involving  domestic  violence  can  be 
presented  during  rotations.  For  example,  dur- 
ing a third  year  Emergency  Medicine  rotation, 
the  instructor  discusses  a woman  with  a history 
of  trauma  injuries  presenting  in  the  emergency 
department  with  a fractured  radius  from  a "bike 
accident."  The  students  can  be  alerted  to  the 
possibility  of  a domestic  violence  situation  and 
can  be  instructed  on  counseling  and  referral  to 
a shelter. 

For  physicians,  domestic  violence  education 
can  be  aggressively  promoted.  Physicians  can 
earn  continuing  education  credits  for  their  time 
and  effort  concerning  this  important  public 
health  issue.  Most  practicing  physicians  have 
never  received  education  in  any  aspect  of  fam- 
ily violence.5  Workshops  and  conferences  can  be 
presented  throughout  the  state.  Workshops  can 
be  made  available  for  rural  physicians  of  Loui- 
siana, where  other  services  such  as  battered 
women's  shelters  are  not  readily  available.  In 
rural  Louisiana,  the  physician  is  one  of  the  few 
resources  for  victims  of  domestic  violence. 

The  program  would  have  five  basic  divisions: 
(1)  Awareness,  (2)  Screening,  (3)  Diagnosis,  (4) 
Legal  Issues,  and  (5)  Counseling  and  Referral. 

AWARENESS 

Clinicians  must  recognize  the  universality  of 
domestic  violence.  In  a study  by  Gula  et  al,  cli- 
nicians consistently  picked  photographs  of  cer- 
tain women  as  exemplars  of  battered  and  non- 
battered  women.  Categorizations  did  not  corre- 
spond with  the  women's  actual  status.6  Domes- 
tic violence  affects  all  races,  religions,  and  so- 
cioeconomic classes.  According  to  the  US  De- 
partment of  Justice,  there  was  not  a significant 
difference  between  blacks  and  whites  in  the  rate 


of  violent  victimizations  that  were  committed 
by  relatives  in  1991.  More  than  18%  of  abusers 
had  a bachelors  degree  or  higher,  and  the  aver- 
age age  of  the  offender  was  31  years.7  Prevalence 
and  other  current  statistics  on  patient  popula- 
tion can  be  made  available  for  physicians  to  raise 
their  awareness  of  this  far-reaching  problem. 

SCREENING 

Because  of  the  diverse  group  that  can  be  affected 
by  domestic  violence,  it  is  important  to  screen 
all  patients  and  investigate  patients  whom  the 
physician  suspects  may  be  victims.  With  univer- 
sal screening,  more  victims  of  domestic  violence 
can  be  identified  and  can  receive  needed  ser- 
vices.5 Victims  of  family  violence  are  seen  in  ev- 
ery venue  of  health  care,  yet  physicians  do  not 
routinely  inquire  about  abuse,  even  when  pa- 
tients present  with  obvious  clinical  characteris- 
tics. How  does  a physician  actually  screen  for 
domestic  violence? 

It  is  important  to  ask  all  women  about  pos- 
sible abuse  or  sexual  assault.  The  following  are 
some  questions  physicians  can  ask: 

♦ Have  you  ever  been  physically  hurt  or  threat- 
ened by  your  partner? 

♦ What  stress  do  you  experience  in  your  rela- 
tionships? 

♦ Have  you  felt  afraid  at  times  in  your  rela- 
tionship? 

♦ Has  your  partner  ever  threatened  or  abused 
you  or  your  children? 

The  HITS  scale  is  a promising  domestic  violence 
screening  mnemonic  for  physicians.  It  is  a four- 
item  questionnaire  physicians  can  give  to  each  of 
their  patients  on  the  initial  visit.  The  HITS  scale 
screens  for  being  Hurt,  Insulted,  Threatened  with 
harm,  or  Screamed  at  by  their  partner.8 

Physicians  need  to  initiate  discussions  about 
partner  abuse  and  approach  the  situation  with 
trust,  compassion,  and  understanding.  Physi- 
cians can  push  the  limit  of  current  standard 
screening  procedures  and  ask  all  patients  about 
abusive  situations,  as  men  as  well  as  women 
may  be  in  a domestic  violence  situation.  Accord- 


632  J La  State  Med  Soc  VOL  1 52  December  2000 


Health  Law  and  Biomedical  Ethics 


ing  to  the  US  Department  of  Justice,  men  com- 
prised 15%  of  domestic  violence  cases  reported 
in  19917 

DIAGNOSIS 

Victims  of  domestic  violence  may  exhibit  subtle 
signs  of  abuse.  The  American  Medical  Associa- 
tion notes  that  physical  injuries,  depression,  fa- 
tigue, chronic  pain,  substance  abuse,  and  a pan- 
icky attitude  during  examination  can  all  be  signs 
of  abuse.9  "Even  low  severity  violence  is  associ- 
ated with  physical  and  psychological  health 
problems  in  women."10 

In  the  emergency  room,  the  nature  of  the  in- 
jury may  signal  trauma  from  abuse.  Compared 
to  patients  who  present  with  unintentional  in- 
juries, women  with  assault-related  injuries  have 
a greater  likelihood  of  presenting  with  contu- 
sions, ill-defined  signs  and  symptoms,  and  head 
fractures.  Victims  of  domestic  abuse  more  likely 
presented  between  the  hours  of  6 p.m.  and  6 a.m. 
on  Friday,  Saturday,  and  Sunday  and  had  greater 
history  of  prior  presentations  to  the  emergency 
department.11 

LEGAL 

Physicians  can  be  alerted  to  important  legal  is- 
sues that  may  arise  when  handling  an  abuse 
case.  Physicians  should  document  evidence  of 
attack  or  abuse  and  specify  as  a note  in  hospital 
records  or  charts  by  using  wording  such  as  "the 
patient  states...". 

If  abuse  is  suspected  and  denied  by  the  pa- 
tient, physicians  can  record  that  the  patient's 
explanation  of  injuries  is  not  supported  upon 
physical  examination.  Currently  there  is  no  man- 
datory reporting  law  for  domestic  violence  in 
Louisiana.  Physicians  need  to  be  aware  of  main- 
taining confidentiality  and  fidelity  with  their 
patients. 

COUNSELING  AND  REFERRAL 

Physicians  can  be  informed  of  resources  and 
services  available  in  the  area.  Physicians  can 
make  proper  referrals  to  psychiatric,  medical, 
and  social  services  with  the  patient's  consent. 


Some  services  available  locally  and  nation- 
ally include: 

♦ Louisiana  Coalition  Against  Domestic 
Violence 

P.O.  Box  77308 
Baton  Rouge,  La  70809-7308 
Phone:  225.752.1296 
FAX:  225.751.8927 

1.800. 799. SAFE  or  1.800.787.3224  (TDD) 

♦ The  Good  Samaritan  Homeless  Center  for 
Women  and  Children 
www.helpforwomen.org 

♦ State  of  Louisiana  Governor's  Office  of 
Women's  Services 

225.922.0960 

♦ Family  Counseling  Agency  Turning  Point 
Shelter 

Alexandria,  La 
318.445.2022;  1.800.960.9436 

♦ Safe  Harbor 
Slidell,  La 
504.643.9407 

♦ YWCA  Family  Violence  Program 
Shreveport,  La 
318.222.2117;  1.800.338.6536 

♦ YWCA  Battered  Women's  Program 
New  Orleans,  La 
504.523.3755 

♦ June  Jenkins  Women's  Shelter 
DeRidder,  La 
337.462.6504 

♦ CHEZ  Hope 
Franklin,  La 
1.800.331.5303 

♦ Calcasieu  Women's  Shelter 
Lake  Charles,  La 
337.436.4552;  1.800.223.8066 


J La  State  Med  Soc  VOL  1 52  December  2000  633 


Health  Law  and  Biomedical  Ethics 


Physicians  should  assess  level  of  danger  in 
the  situation  and,  when  appropriate,  secure  a 
safe  place  for  the  patient.  Physicians  should  en- 
courage individual  choice  and  decision  making. 
They  can  assure  patients  of  the  sacred  doctor- 
patient  relationship  and  open  their  offices  as  a 
safe  place  to  receive  unbiased,  confidential  medi- 
cal treatment. 

In  conclusion,  domestic  violence  is  indeed 
an  epidemic.  Intervention  through  laws  is  a pos- 
sibility. However,  California's  mandatory  report- 
ing law  demonstrates  the  problems  with  such  a 
law.  Perhaps  the  best  venue  for  increasing  aware- 
ness, helping  more  victims,  and  curbing  this 
epidemic  is  to  implement  a comprehensive  edu- 
cation program  for  physicians.  Statewide  sup- 
port for  conferences  and  workshops  may  help. 
After  implementing  such  a program,  it  is  even 
more  important  to  evaluate  the  efficacy  of  the 
program.  More  clinically  relevant  education  at 
all  levels  of  medical  training  can  help  save  lives. 

REFERRENCES: 

1.  Alpert  EJ,  Tonkin  AE,  Seeherrman  AM,  et  al.  Fam- 
ily violence  curricula  in  US  medical  schools.  Am  J 
PrevMed  1998;14:273-282. 

2.  Glazer  S.  Violence  against  women.  Congressional 
Quarterly ;3 : 1 71  - 1 72 . 

3.  Sachs  CJ,  Peek  C,  Baraff  LJ.  Failure  of  mandatory 
domestic  violence  reporting  law  to  increase  medi- 
cal referral  to  police.  Ann  EmergMed  1998;31:488- 
494. 

4.  Rodriguez  MA,  Craig  AM,  Mooney  DR,  et  al.  Pa- 
tient attitudes  about  mandatory  reporting  of  do- 
mestic violence:  implications  for  health  care  pro- 
fessionals. West  J Med  1998;169:337-341. 

5.  Horan  DL,  Chapin  J,  Klein  L,  et  al.  Domestic  vio- 
lence screening  practices  of  obstetrician-gynecolo- 
gists. Obstet  Gynecol  1998;92:785-789. 

6.  Gula  CA,  Yarmel  AD.  Physical  appearance  and 
judgment  of  status  as  battered  women.  Perceptual 
and  Motor  Skills  1998;87:459-465. 

7.  Criminal  Victimiza  tion  in  the  US/ 1 991 . Washington, 
DC:  US  Dept  Justice,  Bureau  Justice  Statist;  1992. 

8.  Sherin  KM,  Sinacore  JM,  Li  XQ,  et  al.  HITS,  a short 
domestic  violence  screening  tool  for  use  in  a fam- 
ily practice  setting.  Fam  Med  1998;30:508-. 

9.  Smolowe  J.  When  violence  hits  home.  Time 
1994;144:27-39. 


10.  McCauley  J,  Kern  DE,  Koloder  K,  et  al.  Relation  of 
low  severity  violence  to  women's  health.  / Gen  In- 
tern Med  1998;13:687-691. 

11.  Fanslow  JL,  Norton  RN,  Spinola  CG.  Indicators  of 
assault-related  injuries  among  women  presenting 
to  the  emergency  department.  Ann  Emerg  Med 
1998;32:314-318. 


Ms  Kang  holds  a Bachelor  of  Arts  degree  in  English  from 
Louisiana  State  University  - Baton  Rouge. 
She  is  a third  year  medical  student  at  Louisiana  State 
University  Health  Sciences  Center  in  New  Orleans , 
Louisiana.  Concurrently  with  her  medical  studies , she  is 
completing  a Master  of  Public  Health  degree. 
Her  hometown  is  Welsh , Louisiana. 


634  J La  State  Med  Soc  VOL  152  December  2000 


Health  Law  and  Biomedical  Ethics 


Physician  Unions  - An  Ethical  and  Legal 
Issue  in  Health  Care  Delivery 


Benjamin  K.  Canales,  BS 


The  controversial  issue  of  physicians'  unions  has  been  revived  in  the  past  few  years  by  the 
economic  juggernaut  of  managed  care.  The  uproar  of  legal  and  ethical  dilemmas  surrounding 
the  creation  of  physician  unions  centers  around  self-employed  physicians,  their  formal 
employment  relationship  to  HMOs  under  the  National  Labor  Relations  Act,  and  the 
ramifications  of  exempting  physicians  from  current  antitrust  laws.  Will  physician  collective 
bargaining  increase  competition  and  equalize  the  power  between  physicians  and  HMOs  so 
that  the  quality  of  patient  care  improves?  This  report  discusses  relevant  laws  and  the  history 
of  physicians'  unionization,  reviews  contemporary  thought  and  present  policies  on  physician 
unionization,  and  comments  on  alternatives  and  new  policies  that  could  be  created  in  order  to 
resolve  this  dilemma. 


I.  PHYSICIAN  UNIONS  - AN  ETHICAL  AND 
LEGAL  ISSUE  IN  HEALTH  CARE  DELIVERY 

Managed  care  is  perhaps  the  most  contentious 
subject  in  the  US  health  care  industry.  Depend- 
ing on  your  viewpoint,  it  is  either  a necessary 
discipline  to  control  costs,  or  a blunt  tool  to  en- 
rich insurers  and  employers  at  the  expense  of 
patients  and  physicians.  One  thing  is  certain 
however:  over  the  past  2 decades,  the  arena  in 
which  physicians  provide  professional  services 
to  patients  has  changed  radically.  In  the  past, 
individual  and  small  groups  of  physicians  have 
provided  the  majority  of  services  to  patients. 


Now  that  the  system  is  becoming  more  inte- 
grated and  consolidated,  many  physicians  are 
finding  themselves  working  with  larger  inte- 
grated health  systems  and  health  maintenance 
organizations,  negotiating  contractual  terms 
that  are  beyond  their  expertise,  or  trying  to 
balance  time  and  money  with  patient  care  and 
workplace  issues.  With  all  these  concerns,  it  is 
no  wonder  that  managed  care  has  revived  the 
controversial  idea  of  physicians'  unions.  Un- 
der current  federal  laws  (which  will  be  dis- 
cussed fully  elsewhere  in  this  paper),  physi- 
cians not  in  an  employment  relationship,  like 


J La  State  Med  Soc  VOL  152  December  2000  635 


Health  Law  and  Biomedical  Ethics 


self-employed  physicians,  are  viewed  as  com- 
petitors with  each  other,  and  therefore  may  not 
unionize  to  increase  bargaining  power  or  level 
the  playing  field  with  HMOs.  This  step  is  neces- 
sary, contend  some  physicians,  if  they  are  to 
properly  care  for  patients  and  wrest  back  con- 
trol of  their  profession.  Why  has  there  been  such 
an  uproar  of  legal  and  ethical  dilemmas  sur- 
rounding the  creation  of  physician  unions,  and 
what  are  the  ramifications  if  such  laws  are 
passed?  This  report  discusses  relevant  laws  and 
the  history  of  physicians'  unionization,  reviews 
contemporary  thought,  presents  policies  on  phy- 
sician unionization,  and  comments  on  alterna- 
tives and  new  policies  that  could  be  created  in 
order  to  resolve  this  dilemma. 

II.  POLICIES,  LAWS  AND  THE  HISTORY  OF 
PHYSICIAN  UNIONS 

The  primary  set  of  laws  that  impede  physician 
unionization  are  the  antitrust  laws  and  their 
applicability  to  joint  action  by  independent  eco- 
nomic entities.1  These  laws  effectively  bar  "self- 
employed"  physicians,  or  any  independent  phy- 
sician group,  from  acting  collectively  with  other 
physicians  or  groups  in  negotiating  economic 
terms  with  health  plans.  After  the  antitrust  laws 
were  passed  in  the  late  1800s,  they  were  consid- 
ered applicable  to  labor  organizing  and  were 
used  to  enjoin  strikes.2  Subsequently,  Congress 
passed  the  Clayton  Act,  which  provides  in  per- 
tinent part  that  "the  labor  of  a human  being  is 
not  a commodity  or  an  article  of  commerce",  and 
that  "nothing  contained  in  the  antitrust  laws 
shall  be  construed  to  forbid  the  existence  and 
operation  of  labor. . .organizations."3  In  addition, 
section  20  of  the  Act  specified  that  certain  ac- 
tivities, such  as  strikes,  picketing,  and  boycotts 
cannot  be  enjoined  by  a federal  court  when  con- 
ducted as  part  of  "a  dispute  concerning  the  terms 
of  conditions  of  employment."4  After  the  creation 
of  these  labor  laws,  exemptions  from  the  anti- 
trust laws  could  now  be  made  that  allowed  la- 
bor organizations  and  their  members  to  legiti- 
mately engage  in  collective  negotiation  over 
terms  and  conditions  of  employment.  To  fall 


within  the  labor  exemption,  the  conduct  must 
arise  out  of  a labor  dispute  between  an  employer 
and  its  employees.  In  other  words,  the  labor  ex- 
emption is  contingent  upon  an  employment  re- 
lationship. Only  employees  who  are  not  supervi- 
sors or  managers  ("non-supervisory  employees") 
may  form  a collective  bargaining  unit  to  negoti- 
ate with  their  employers  under  the  labor  laws. 

The  core  problem  that  arose  after  these  laws 
were  passed  was  the  conflict  between  the  goals 
of  the  antitrust  laws  and  the  labor  laws.  The 
purpose  of  the  antitrust  laws  was  to  promote 
competition  among  providers  of  goods  and  ser- 
vices as  a way  to  enhance  consumer  welfare. 
Competition  leads  to  greater  diversity  among 
products  and  services,  better  quality,  and  lower 
prices.  Therefore,  the  antitrust  laws  bar  combi- 
nations and  other  collective  actions  among  sell- 
ers or  buyers  of  goods  and  services  to  raise  prices 
or  otherwise  set  the  terms  of  dealing.  Notwith- 
standing the  apparent  clarity  of  the  Clayton  Act, 
in  1932  Congress  passed  the  Norris  Laguardia 
Act,5  which  declared  a national  public  policy  in 
favor  of  labor  unions  and  stated  that  collective 
bargaining  and  union  organization  are  protected 
activities. 

Three  years  after  the  Norris  Laguardia  Act, 
Congress  passed  the  National  Labor  Relations  Act 
(also  known  as  the  Wagner  Act)  which  created 
the  National  Labor  Relations  Board  and  is  the 
basis  for  today's  comprehensive  federal  labor 
regulation.  This  Act  does  not  contain  an  express 
exemption  from  the  antitrust  laws,  but  rather,  it 
was  designed  to  protect  the  activities  of  labor  or- 
ganizations and  the  persons  that  participate  in 
them.  Nonetheless,  it  is  a reference  point  for  de- 
fining the  legitimate  labor  activities  that  are  ex- 
empt from  the  antitrust  laws.  The  Act  created  a 
legally  enforceable  right  for  employees  to  orga- 
nize, required  employers  to  bargain  with  employ- 
ees through  employee  elected  representatives, 
and  gave  employees  the  right  to  engage  in  con- 
certed activities  for  collective  bargaining  purposes 
or  other  mutual  aid  or  protection.1 

After  several  other  minor  acts  were  passed, 
physicians  employed  directly  by  hospitals  and 
clinics  began  to  unionize.  Physician  unions  first 


636  J La  State  Med  Soc  VOL  152  December  2000 


Health  Law  and  Biomedical  Ethics 


came  on  the  scene  in  1957  when  the  Committee 
of  Interns  and  Residents  affiliated  with  the  Ser- 
vice Employees  International  Union  began  to 
represent  resident  physicians  from  public  hos- 
pitals around  the  country.  Currently,  about 
35,000  US  doctors  (5%  of  American  doctors)  be- 
long to  unions  (up  from  25,000  in  1996),  and 
about  half  of  the  US  states  currently  have  labor 
unions  representing  physicians.  The  longest-last- 
ing and  most  successful  physicians'  union,  the 
Union  of  American  Physicians  and  Dentists 
(UAPD)  was  formed  in  1972.6  Obviously,  hospi- 
tals have  long  recognized  doctors  as  a bargain- 
ing unit  in  negotiations,  so  why  the  uproar  now? 

Under  current  antitrust  law,  the  only  way 
physicians  can  bargain  collectively,  regardless 
of  what  the  activity  is  called,  is  in  the  context  of 
a formal  employment  relationship  as  defined  un- 
der the  National  Labor  Relations  Act.  Unless 
they  are  part  of  an  integrated  group  practice,  self- 
employed  physicians  can  not  bargain  collectively 
with  payors  because  doing  so  would  be  a viola- 
tion of  antitrust  laws  that  carry  potential  crimi- 
nal penalties  and  treble  damages.  So,  as  justice 
would  have  it,  federal  antitrust  laws  bar  self- 
employed  physicians  (who  account  for  about 
75%  of  the  nation's  684,000  physicians)  from 
bargaining  - the  same  physicians  who  are  most 
at  the  mercy  of  managed  care's  economic  jug- 
gernaut of  the  1990s.  It  is  the  leverage  ability  of 
these  managed  care  empires  (directing  large 
volumes  of  patients  to  selected  physicians  and 
denying  those  patients  access  to  other  physi- 
cians) that  has  led  the  American  Medical  Asso- 
ciation (AMA)  as  well  as  many  private  physi- 
cians and  groups  to  begin  challenging  the  legal 
precedent  of  unionization  through  various 
means. 

Historically,  the  AMA  has  considered  that  the 
unions'  traditional  emphasis  on  collective  action 
through  strict  majority  rule  is  ill-suited  to  the 
professional  values  of  the  medical  profession. 
The  AMA  claims  that  the  objectives  of  the  unions 
do  not  lend  themselves  well  to  the  goals  of  phy- 
sicians (which  are  personal  autonomy  and  qual- 
ity patient  welfare),  and  it  held  strongly  to  this 
position  until  1993.  At  this  time,  the  AMA  an- 


nounced that  it  was  easing  its  opposition  to  phy- 
sician collective  bargaining  and  supporting  pro- 
grams that  educate  physicians  on  managed  care 
issues.  Because  the  AMA  feared  that  without 
bargaining  rights  the  private  physician  was  pow- 
erless in  this  era  of  managed  health  care,  its 
House  of  Delegates  passed  a resolution  (1997) 
directing  the  AMA  to  draft  legislation  to  allow 
self-employed  physicians  to  form  collective  bar- 
gaining units  to  bargain  with  managed  health 
care  companies.  In  an  attempt  to  curb  the  AMA's 
efforts,  on  May  24,  1999,  National  Labor  Rela- 
tions Board  (NLRB)  regional  director  Dorothy 
Moore-Duncan  dismissed  AmeriHealth  Inc./ 
AmeriHealth  HMO  and  United  Food  & Commer- 
cial Workers  Union,  Local  56,  No.  4-RC-19260, 326 
N.L.R.B.  No.  55,  holding  that  the  650  physicians 
seeking  to  unionize  were  not  employees  of 
AmeriHealth  HMO,  Inc.  Instead,  her  ruling 
identified  the  physicians  as  independent  con- 
tractors who  are  not  permitted  to  unionize. 

AmeriHealth  originated  in  New  Jersey,  where 
650  primary  care  and  specialty  physicians  with 
both  solo  and  group  practices  attempted  to  or- 
ganize a collective  bargaining  unit.  To  gain  mem- 
bership in  the  United  Lood  and  Commercial 
Workers  Local  56,  the  union  filed  a petition  with 
NLRB  in  October  1997  seeking  to  represent  the 
doctors.  In  January  1998,  Moore-Duncan  dis- 
missed the  petition  for  failure  to  show  "whether 
there  is  reasonable  cause  to  believe  that  the  pe- 
tition raises  a question  ...  as  to  whether  the  pri- 
mary care  and  specialty  physicians  are  or  are  not 
employees."6  On  appeal,  Moore-Duncan  con- 
cluded that  the  relatively  small  clientele  from 
AmeriHealth  (in  comparison  with  the  doctors' 
full  patient  loads)  coupled  with  the  flexibility 
that  doctors  maintained  in  setting  their  hours, 
working  with  other  insurance  companies,  secur- 
ing their  own  office  space,  and  hiring  their  own 
staff,  allowed  doctors  to  retain  their  independent 
status.  Moore-Duncan  made  her  holding  despite 
the  non-negotiability  and  indefinite  length  of 
physicians'  agreements,  as  well  as  the  health 
maintenance  organization's  requirements  for 
pre-approval  of  surgery  - all  of  which  blurred 
their  employment  status  as  private  practitioners. 


J La  State  Med  Soc  VOL  152  December  2000  637 


Health  Law  and  Biomedical  Ethics 


The  current  standard  for  determining  employee 
or  independent  contractor  status  is  found  in  the 
Resta  tement  (Second ) of  Agency,  § 220,  which  lists 
ten  criteria  for  determining  employee  status. 

Despite  this  ruling,  developments  in  other  ju- 
risdictions and  in  the  state  and  federal  legisla- 
tures indicate  that  physicians  are  having  some 
success  forming  unions.  One  such  attempt  at  dis- 
mantling the  statutory  prohibitions  against  phy- 
sician unionization  comes  from  the  House  Judi- 
ciary Committee's  " Quality  Health-Care  Coalition 
Act  of  1999,  H.R.  1304  (Campbell  Bill)"  proposed 
by  Tom  Campbell  (R-CA)  and  John  Conyers  (D- 
MI).7  The  bill  seeks  to  exempt  physicians  and  all 
other  health  care  professionals  from  the  antitrust 
laws  that  currently  hamper  their  unionization  ef- 
forts, claiming  that  physician  collective  bargain- 
ing will  increase  competition  and  equalize  the 
power  between  physicians  and  HMOs  so  that  the 
quality  of  patient  care  improves.  The  Campbell 
Bill  passed  the  House  on  June  29,  2000;  however, 
despite  efforts  by  the  AMA,  state  medical  societ- 
ies, specialty  societies  and  individual  physicians, 
the  bill  did  not  pass  the  Senate  and  is  now  dead. 
The  AMA  reamins  hopeful  that  this  partial  vic- 
tory may  in  the  future  help  pass  a new  version  of 
the  bill  in  both  chambers. 

The  AMA  Board  of  Trustees  has  also  retali- 
ated to  the  AmeriHealth  ruling  by  creating  (in 
September  1999)  the  framework  for  the  physi- 
cian collective  bargaining  unit  called  "Physicians 
for  Responsible  Negotiations".  The  AMA  chose 
the  long  version  of  the  commonly  used  acronym 
"PRN"  (a  term  the  medical  community  knows 
as  meaning  to  take  "as  needed")  for  its  conser- 
vative, grassroots  campaign  to  rally  support 
from  physicians  across  the  country.  This  is  the 
AMA's  alternative  approach  to  traditional  labor 
unions  - unions  which  they  feel  "are  actively 
organizing  and  recruiting  physicians",  said  Dr 
Thomas  Reardon,  the  AMA  president.8  The 
AMA's  union  will  not  strike,  recruit  members, 
or  even  petition  the  National  Labor  Relations 
Board  once  enough  doctors  are  ready  to  sign  up. 
Instead,  the  AMA  is  offering  doctors  a "do-it- 
yourself"  organizational  structure,  providing 
them  with  a 20-page  constitution9  and  outside 


legal  help  should  they  want  a collective  bargain- 
ing unit  in  their  own  locale.  Interested  doctors 
would  have  to  petition  the  NLRB  on  their  own 
for  union  recognition.  Other  test  cases  include 
physicians  in  Tucson,  Arizona,  who  joined  the 
Federation  of  Dentists  and  Physicians  in  order 
to  bargain  collectively  with  the  Thomas-Davis 
Medical  Clinic,10  and  the  Medalia  Health  Care 
Center  case  in  Seattle,  Washington.6 

III.  ALTERNATIVES  TO  CURRENT  POLICY 

Physician-owned  and  -controlled  practice  man- 
agement companies  are  becoming  more  com- 
mon and  hold  the  promise  of  allowing  physi- 
cians to  collectively  bargain  with  managed  care 
plans  and  suppliers,  while  reaping  the  benefits 
of  professional  management  and  marketing  they 
could  never  afford  on  their  own.  Instead  of  sell- 
ing out  and  going  to  work  for  some  large  im- 
personal company,  physicians  who  set  up  their 
own  management  companies  can  "go  public". 
By  selling  a small  percentage  of  their  companies' 
shares  to  the  public,  physicians  get  others  to  in- 
vest in  their  future  while  they  (the  physicians) 
retain  control.11  Physicians  can  join  together 
(usually  along  specialty  lines)  to  access  capital 
necessary  to  grow  their  practices  and  necessary 
to  incorporate  laboratories,  ambulatory  care  cen- 
ters, surgical  centers,  and  other  facilities  within 
their  practices  as  well  as  to  attract  world  class 
management  who  would  install  information 
systems  and  permit  quality  management,  effec- 
tive marketing,  and  contract  negotiations.12  With 
the  proper  structure,  physicians  will  then  be  able 
to  legally  bargain  collectively  with  managed  care 
companies  and  other  payors.  Once  the  profes- 
sional corporation  forms,  it  creates  its  own  phy- 
sician practice  management  company  (PPM). 

The  physicians  control  all  of  the  stock  of  the 
professional  corporation  and  a large  majority  of 
the  stock  of  the  PPM.  The  remaining  PPM  stock 
is  used  to  attract  high  quality  management  and, 
ultimately,  capital.  Since  the  project  can  be  struc- 
tured initially  as  a bankable  transaction,  no  ven- 
ture capital  is  required,  thus  maximizing  physi- 
cian ownership  in  the  PPM.  Moreover,  due  to 


638  J La  State  Med  Soc  VOL  152  December  2000 


Health  Law  and  Biomedical  Ethics 


the  availability  of  stock,  the  physicians  need  take 
no  money  out  of  their  own  pockets  to  form  these 
ventures.  Rather,  as  part  of  the  package,  it  is  not 
unusual  for  physicians  to  receive  stock  and  cash 
equal  to  as  much  as  their  previous  year's  actual 
collections.  For  this  to  work,  physicians  in  the 
same  or  similar  specialties  must  bring  their  prac- 
tices together  into  a single,  regional  professional 
corporation.  This  does  not  mean  that  the  physi- 
cians lose  their  existing  practices  or  the  indi- 
vidual character  of  their  offices.  The  physicians' 
existing  practices  continue,  as  individual  care 
centers,  within  the  larger  context  of  an  umbrella 
professional  corporation.  These  physicians  are 
not  running  away  from  their  patients  or  from 
all  that  they  have  worked  for;  instead,  they  are 
taking  responsibility  for  their  own  destiny  and 
proving  that  physicians  do  have  a place  in  health 
care  management.11 

Also,  physicians  should  not  forget  that  their 
state  and  county  medical  societies  are  there  to 
help  them  meet  these  challenges  as  they  have 
been  in  the  past.  For  example,  when  Occupa- 
tional Safety  and  Health  Administration's  new 
and  complex  rules  and  guidelines  threatened  the 
practice  of  medicine,  state  and  local  medical  so- 
cieties issued  policies  at  incredible  speed.  The 
societies'  and  the  state's  physician  political  ac- 
tion committees  (PACs)  should  be  rallying  points 
for  physicians.  Unfortunately,  though,  too  many 
physicians  do  not  join  the  societies  or  contrib- 
ute to  the  PACs.  Some  are  turned  off  by  what 
they  believe  to  be  the  overtly  political  nature  of 
the  societies  or  the  costs  of  participation.  Yet, 
unions  are  not  going  to  be  any  less  political  or 
costly.  Whatever  their  excuse  may  be,  physicians 
should  be  aware  that  their  state  and  county  (par- 
ish) medical  and  speciality  societies  are  their 
voice  on  organizing  - whether  as  a collective 
management  company,  a union,  or  a merged 
group. 

State  legislatures  are  also  initiating  changes. 
For  instance,  in  February  1999,  the  AMA  Board 
of  Trustees  approved  model  state  legislation 
through  which  states  could  provide  immunity 
for  certain  collective  activities  by  physicians. 
This  legislation  is  modeled  on  the  "state  action 


doctrine",  a court-created  exemption  to  the  an- 
titrust laws.  Under  the  "state  action  doctrine" 
the  antitrust  laws  do  not  apply  to  collective  ac- 
tion compelled  or  approved  by  a state,  which  is 
pursuant  to  "clearly  articulated  and  affirmatively 
expressed  state  policy."2  The  Texas  Medical  As- 
sociation immediately  introduced  legislation, 
patterned  on  the  AMA  model  in  both  the  Texas 
House  and  Senate.  The  bill  entitled  the  "Managed 
Care  Freedom  of  Choice  Act"  was  subsequently 
passed  by  both  the  Senate  and  the  House  in  late 
May  and  was  recently  signed  by  Texas  Governor 
George  W.  Bush  into  action  — permitting  a per- 
centage of  independent  Texas  doctors  to  negoti- 
ate collectively  with  health  insurers.  The  Penn- 
sylvania Medical  Society  has  drafted  legislation 
on  this  model,  and  Washington,  DC,  New  Jersey, 
and  Georgia  are  also  considering  drafting  simi- 
lar legislation  for  this  session. 

IV.  SOLUTIONS  FOR  POLICY 
MANAGEMENT 

I feel  that  a national  reform  of  labor  laws  would 
be  a violation  of  antitrust  and  that  it  would  be 
unwise  to  pass  a blanket  law  stating  that  all  phy- 
sicians are  exempted  from  the  labor  laws  and 
can  bargain  collectively.  Physicians  always  have 
had  a fiduciary  relationship  with  the  patient,  and 
trust  has  been  (and  hopefully  still  is)  the  corner- 
stone of  the  physician-patient  relationship.  In 
order  not  to  jeopardize  that  physician-patient 
relationship,  I believe  the  dilemma  facing  inde- 
pendent physicians  can  be  solved  by  physicians 
focusing  on  their  own  private  practice  (ie,  creat- 
ing strong  PPMs  or  other  such  fiscally  indepen- 
dent groups)  and  by  physicians  initiating  union- 
like change  on  state  and  local  levels.  Legislatures 
and  courts  should  be  sensitive  to  the  needs  of 
physicians  to  even  out  the  bargaining  field 
against  HMOs,  and  new  laws  should  permit 
physicians  to  form  professional  associations 
under  the  auspices  of  the  AMA  to  negotiate  on  a 
more  united  front  against  HMOs.  These  laws 
should  increase  physicians'  bargaining  power 
and  hopefully  would  provide  physicians  oppor- 
tunities to  voice  their  demands  without  resort- 


J La  State  Med  Soc  VOL  1 52  December  2000  639 


Health  Law  and  Biomedical  Ethics 


ing  to  union  tactics.  I like  the  way  the  AMA 
strives  to  steer  clear  of  these  strike  tactics  and 
organize  and  develop  unions  through  affiliations 
with  state  and  county  (parish)  medical  societ- 
ies. I feel  that  only  through  this  slow,  grassroots 
approach  will  physicians  maintain  their  profes- 
sionalism while  protecting  their  patients'  inter- 
ests on  such  vital  issues  as  compensation  and 
decision-making  power. 

V.  UNION  STRIKES  AND  ECONOMIC 
ADVANTAGE 

Of  course  when  speaking  of  any  type  of  orga- 
nized labor,  there  is  always  the  fear  of  strikes. 
One  can  only  imagine  the  havoc  that  might 
wreck  the  medical  profession  if  unions,  however 
large  or  small,  are  allowed  to  collectively  repre- 
sent physicians  in  the  United  States.  There  could 
be  drawn-out  negotiations  between  unions  and 
HMOs  that  prevent  physicians  from  treating 
patients.  The  fear  of  work  stoppage  if  the  sides 
do  not  reach  an  agreement  could  paralyze  the 
medical  system.  And  the  sight  of  physicians  in 
white  lab  coats  picketing  in  front  of  hospitals  is 
an  unspeakable  reality  that  should  be  addressed. 
Unfortunately,  we  are  now  in  a social  environ- 
ment which  seems  to  only  respond  to  work  stop- 
pages. Picture  the  multiple  times  that  miners, 
teachers,  auto  workers,  dock  workers,  truck 
drivers,  baseball  players,  etc.  have  done  this  in 
order  to  get  recognition  of  a problem  (and  the 
economic  pressure  and  inconvenience  produced 
a response  not  seen  prior  to  the  work  stoppage!). 
Unions  stand  to  gain  much  power  and  revenue 
if  independent-practice  and  supervisory  physi- 
cians are  considered  employees,  and  already 
many  unions  are  organizing  physicians  for  col- 
lective bargaining.  Unions  in  our  society  have 
been  notorious  not  for  consumer  protection,  but 
for  extracting  benefits  for  their  members.  Asso- 
ciation of  American  Medical  Colleges  (AAMC) 
President  Jordan  J.  Cohen  worries  that  economic 
advantage,  not  high-minded  altruism,  will  be 
what  most  people  will  perceive  as  the  motive 
behind  the  unionization  decision.  More  than 
that.  Dr  Cohen  believes  that  the  AMA's  decision 


could  threaten  the  doctor-patient  relationship 
upon  which  the  profession  is  based.  "Trust  can't 
be  acquired  through  negotiation  across  a bar- 
gaining table.  It  has  to  be  earned.  Doctors  seek- 
ing marketplace  leverage  through  unions  are 
trading  their  most  valuable  asset  for 
commercialism's  promise  of  a quick  fix — a ru- 
inous trade,  and  one  that  simply  won't  work."13 

Overall,  the  record  shows  that  existing 
unions  have  had  little  success  in  helping  physi- 
cians solve  disputes  with  hospitals  and  health 
plans.  With  state  and  local  changes  on  the  hori- 
zon and  with  physician  practice  management 
companies  providing  physicians  with  capital 
and  independence,  it  is  my  hope  that  some  sort 
of  compromise  can  be  reached.  Obviously,  phy- 
sicians and  patients  need  a stronger  podium 
from  which  to  speak  and  be  recognized  by  soci- 
ety and  insurers.  Seeing  that  the  resolution  of 
this  issue  will  greatly  affect  the  medical  profes- 
sion, legislators  and  courts  should  not  be  hasty 
in  changing  the  status  quo  but  should  be  wise 
in  their  passage  of  laws  and  policies  that  have 
the  patient's  best  interests  at  heart. 

REFERENCES 

1.  Hirshfeld  E B.  Physicians,  Union,  and  Anti-trust. 
Presentation  to  the  American  Health  Lawyers 
Association,  August  1998. 

2.  Gifford  D J.  Redefining  the  Antitrust  Labor 
Exemption.  Minnesota  Law  Review.  1988;72:1376- 
1381. 

3.  Clayton  Act  § 6,  15  U.S.C.  § 17. 

4.  29  U.S.C.  § 52. 

5.  29  U.S.C.  § 101-115. 

6.  Dickinson  C.  NLRB  and  renewed  efforts  by 
physicians  to  unionize.  J Health  Law  Med  Ethics. 
1999;27:283-284. 

7.  Health-Care  Coalition  Act  of  1999.  H.R.  1304, 106th 
Congress,  1999. 

8.  Japsen  B.  AMA  tells  docs  to  organize  on  as-needed 
basis.  Chicago  Tribune.  September  10,  1999.  Avail- 
able at:  http:/ /www.chicagotribune. com/business 
/businessnews  / article 

9.  Report  30  of  the  AMA  Board  of  Trustees  - Collec- 
tive Bargaining  as  an  AMA  Advocacy  Tool  (Refer- 
ence Committee  I).  September,  1999.  Available  at: 
http : / / www.ama-assn.org  / meetings  / public  / an- 
nual99/reports/bot/botrtf/botrep30.rtf 


640  J La  State  Med  Soc  VOL  152  December  2000 


Health  Law  and  Biomedical  Ethics 


10.  Thomas-Davis  Medical  Clinic,  No.  28-RC-5449, 324 
N.L.R.B.  No.  15,  1997. 

11 . Conroy  R,  Kern  S.  Physicians  unions  - barriers  and 
alternatives.  From  Kern,  Augustine,  Conroy  & 
Schoppmann  Health  Law  Professional  Consultants. 
Available  at:  http://www.drlaw.com/oceans.html 

12.  Kern  S I.  Organizing  physicians  - legal  issues.  From 
Kern,  Augustine,  Conroy  & Schoppmann  Health 
Law  Professional  Consultants.  Available  at:  http:/ 
/www.drlaw.com/ mcgee.html 

13.  Whitcomb  M.  No  unity  on  unionization.  The  AAMC 
Reporter.  1999;8:2.  Available  at:  http://www. 
aamc.org/ newsroom/ reporter/ sept99/ union.htm 


Mr  Canales  is  a native  of  Monroe,  Louisiana.  He  holds  a 
Bachelor  of  Science  in  Biology  from  Louisiana  Tech 
University.  He  is  a fourth-year  medical  student  at 
Louisiana  State  University  Health  Sciences  Center  School 
of  Medicine  in  New  Orleans,  Louisiana  and  is  completing 
degree  requirements  for  a Master  of  Public  Health. 


Weekend  Classes  (504)588-5469  www.hsm.tulane.edu/emha 


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can  give  you  the  unique  combination  of  business  and 
health  systems  skills  to  pursue  senior  management 
roles.  Tulane  offers  the  only  accredited  MHA  program 
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nCMLi  n ADMINISTRATION 


What’s  standing 
between  you  and  the 
success  you  want? 


J La  State  Med  Soc  VOL  152  December  2000  641 


Health  Law  and  Biomedical  Ethics 


Cardiopulmonary  Resuscitation 
and  Medical  Ethics 


Lawrence  Montelibano,  BA 


This  paper  presents  an  overview  of  the  ethical  issues  involved  in  creating  policy  regarding 
the  use  of  cardiopulmonary  resuscitation.  Cardiopulmonary  resuscitation  was  introduced 
in  1965  as  a method  to  revive  victims  of  acute  cardiac  insult  from  near-death  conditions. 
The  procedure  is  intended  to  prevent  premature  death;  to  be  effective  it  must  be  initiated 
at  the  very  latest  within  12  minutes  of  cardiac  arrest  (ventricular  fibrillation).  Since  the 
introduction  of  CPR,  the  scope  of  its  use  has  widened  such  that  it  is  often  used  in  situations 
for  which  it  has  shown  little,  if  any,  benefit,  and  also  in  situations  where  it  is 
contraindicated.  This  paper  uses  the  issue  of  CPR  to  show  how  the  bioethical  principles 
of  beneficence,  non-maleficence,  autonomy,  and  justice  can  be  used  to  analyze  issues  in 
medical  ethics. 


Cardiopulmonary  resuscitation,  or  CPR, 
was  introduced  in  1965  as  a method  to 
revive  victims  of  acute  cardiac  insult 
from  near-death  conditions.  CPR  in  its  broad- 
est sense  refers  to  any  of  the  maneuvers  and 
techniques  used  to  restore  spontaneous  circu- 
lation. Basic  CPR  refers  to  the  use  of  the  tech- 
niques of  chest  wall  compressions  and  pulmo- 
nary ventilation.  Advanced  CPR  includes  ad- 
vanced airway  management,  endotracheal  in- 
tubation, defibrillation,  and  intravenous  medi- 
cations. The  procedure  is  intended  to  prevent 
premature  death  and,  in  order  to  be  effective  it 
must  be  initiated  at  the  very  latest  within  twelve 


minutes  after  the  onset  of  cardiac  arrest.  Since 
the  introduction  of  CPR,  the  scope  of  its  use  has 
widened  so  that  almost  all  persons  who  suffer 
cardiac  arrest,  inside  or  outside  the  hospital,  are 
considered  candidates  for  CPR.  In  other  words, 
CPR  has  become  a reflex  response — situations 
that  contraindicate  CPR  are  often  not  consid- 
ered— and  CPR  is  often  overused.  Using  the 
framework  of  the  bioethical  standards  of  benefi- 
cence, non-maleficence,  autonomy,  and  justice 
to  examine  the  appropriateness  of  CPR  in  dif- 
ferent situations,  it  is  possible  to  show  that  in- 
discriminate use  of  CPR  is  not  only  ineffective 
but  also  unethical.  Much  of  the  analysis  pre- 


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Health  Law  and  Biomedical  Ethics 


sented  here  is  a recapitulation  of  analysis  done 
by  Hilberman,  Kutner,  Parsons,  and  Murphy.1 

BENEFICENCE 

First,  the  principle  of  beneficence.  According  to 
this  principle,  moral  agents,  in  this  case  health 
care  workers,  are  obliged  to  take  positive  steps 
to  help  patients  and  act  in  the  patients7  best  in- 
terests. While  good  intentions  accompany  the 
initiation  of  CPR,  we  now  know  that  CPR  is  more 
beneficial  in  some  situations  than  it  is  in  others. 
CPR  has  proven  most  successful,  with  survival 
rates  over  20%,  when  the  cardiac  arrest  occurs 
during  anesthesia,  from  a drug  overdose,  or  with 
a primary  ventricular  arrhythmia.  Patients  sur- 
vive CPR  infrequently  when  non-cardiac  major 
illness  or  organ  dysfunction  precede  the  cardiac 
arrest.  CPR  survival  is  extremely  poor,  less  than 
5%  survival,  when  patients  already  have  renal 
failure,  cancer,  or  AIDS.  CPR  following  trauma, 
hemorrhage,  sustained  hypotension,  or  pneumo- 
nia is  equally  unsuccessful.  In  some  emergency 
medical  systems,  CPR  results  are  so  poor  that  it 
is  worth  considering  changing  policies  so  that 
initiation  of  CPR  becomes  more  the  exception 
than  the  rule.  In  Chicago  and  New  York,  for  ex- 
ample, at  one  point  in  time  less  than  2%  of  pa- 
tients survived  from  field  CPR  to  hospital  dis- 
charge, in  large  part  because  of  the  increased 
travel  times  to  the  patient's  location.1  In  these 
cases,  with  such  poor  outcomes,  it  seems  hard 
to  argue  that  CPR  has  proven  a beneficial  treat- 
ment. CPR  is  not  always  beneficial. 

NON-MALEFICENCE 

The  principle  of  non-maleficence  embodies  the 
"first,  do  no  harm77  edict  of  the  Hippocratic  Oath. 
We  can  test  CPR  policies  against  this  principle 
by  looking  at  the  appropriateness  of  CPR  in  cer- 
tain situations  and  again  at  the  outcomes  of  the 
procedure.  Often,  CPR  involves  a high  risk  of 
debilitating  brain  injury.  With  prolonged  field 
resuscitation,  there  is  a greater  chance  that  those 
who  do  survive  will  do  so  in  a persistent  coma 
or  vegetative  state.  In  comparing  the  value  of 


life  in  a vegetative  state  to  death,  valid  argu- 
ments exist  on  both  sides  as  to  which  is  prefer- 
able. So,  considering  that,  for  many,  life  in  a veg- 
etative state  may  be  an  outcome  worse  than 
death,  many  people  may  consider  CPR  to  be 
maleficent  when  the  risk  of  debilitating  brain 
injury  is  high. 

Many  do-not-resuscitate  (DNR)  policies  and 
CPR  policies,  though  created  to  protect  patients, 
can  actually  lead  to  maleficent  patient  treatment. 
Many  policies  are  designed  to  protect  patients 
from  unilateral  physician  DNR  orders.  In  some 
states,  emergency  crews  are  bound  to  proceed 
with  CPR  despite  evidence  at  the  scene  that  CPR 
is  not  wished  or  otherwise  contraindicated.  Poli- 
cies often  overlook  the  fact  that  resuscitation  can 
only  succeed  if  applied,  at  the  very  latest,  within 
12  minutes  of  the  cardiac  arrest,  since  even  a brief 
interruption  of  blood  flow  to  the  brain  or  heart 
results  in  severe  injury.  In  many  areas,  paramed- 
ics are  required  to  resuscitate  unless  the  victim 
is  decapitated,  in  rigor  mortis,  or  decomposing. 
This  requirement  leads  to  a lot  of  unnecessary 
and  futile  CPR.  There  are  several  possible  sce- 
narios in  which  someone  who  suffered  cardiac 
arrest  more  than  30  minutes  before  the  para- 
medic arrival  would  not  be  decapitated,  decom- 
posing, or  in  rigor  mortis.  CPR  in  these  situa- 
tions would  be  required  by  many  policies  but 
futile  in  all  but  a very  minute  percentage.  These 
policies  reflect  a shift  of  moral  responsibility 
from  the  health  care  worker  to  policies  and  laws 
that  often  conflict  with  the  physician's  judgment 
and  conscience.  A study  by  Marco,  Bessman, 
Schoenfled,  and  Kelen,  shows  that  while  most 
emergency  physicians  honor  legal  advance  di- 
rectives, few  follow  verbal  reports  of  advanced 
directives.2  Fear  of  litigation  or  criticism  moti- 
vates the  decision  making  process  for  many. 
While  most  of  the  emergency  physicians  inter- 
viewed agree  that,  ideally,  legal  concerns  should 
not  influence  resuscitation  decisions,  they  ac- 
knowledge that  in  the  current  environment,  le- 
gal concerns  do  influence  their  practice.  Actions 
that  violate  a physician's  judgment  and  con- 
science may  be  considered  maleficent.  Also,  if  a 
physician  believes  the  verbal  reports  of  an  ad- 


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Health  Law  and  Biomedical  Ethics 


vanced  DNR  directive,  but  continues  CPR  be- 
cause of  a lack  of  a legal  advance  directive,  then 
the  physician  is  essentially  being  forced  by  the 
threat  of  legal  recourse  to  violate  the  patient's 
autonomy. 

The  actual  procedure  of  CPR,  with  often  rib- 
crushing chest  compressions,  is  itself  a violent 
and  some  say  abusive  intervention.  Of  course, 
if  a life  is  saved,  this  is  unimportant.  However, 
the  norm  is  that  CPR  precedes  death,  and  many 
health  care  providers  are  disturbed  when  they 
must  perform  CPR  on  people  afflicted  by  ad- 
vanced illness,  the  debilities  of  old  age,  or  de- 
mentia. While  old  age  alone  is  not  a contraindi- 
cation to  CPR,  when  combined  with  many  asso- 
ciated illnesses  impairing  function,  it  becomes  a 
predictor  of  poor  CPR  outcome.  Following  CPR 
in  public  home  and  nursing  home  settings,  sur- 
vival to  hospital  discharge  is  significantly  less 
for  those  who  already  had  a severe  chronic  dis- 
ease, and  those  who  do  survive  often  return  to 
indignant  conditions  or  die  shortly  after  success- 
ful resuscitation.  While  one  may  argue  that  it  is 
the  health  care  provider's  job  to  save  lives  and 
not  place  any  judgments  on  quality  of  life,  an- 
other may  use  the  above  outcomes  to  argue  that 
under  these  conditions  CPR  is  often  inappropri- 
ate and  accordingly  maleficent.  When  a person's 
quality  of  life  is  characterized  by  advanced  ill- 
ness, dependency,  and/ or  dementia,  the  net  ben- 
efit of  CPR — few  survivors,  all  with  a poor  qual- 
ity of  life — may  not  justify  its  abundant  use. 
Treating  patients  with  an  intervention  that  is 
physically  abusive  and  that  will,  even  if  effec- 
tive, leave  them  in  an  indignant  state,  may  be 
considered  maleficent. 

AUTONOMY 

Most  everyone  supports  the  right  of  a patient  to 
refuse  unwanted  treatments  and  to  be  involved 
in  the  decision  making  regarding  her  own  health, 
but  the  issue  is  complicated  when  it  comes  to 
CPR.  The  CPR  patient  is,  obviously,  not  in  a po- 
sition to  make  her  own  decision  at  the  time  of 
treatment,  and  not  all  patients  have  made  a de- 
cision about  CPR  prior  to  the  time  of  a cardiac 


arrest,  through  a living  will,  a DNR  order,  or 
otherwise.  Even  when  physicians  attempt  to  dis- 
cuss CPR  status  with  a competent  patient,  false 
hope  can  affect  the  patient's  ability  to  make  an 
informed  decision.  Patients,  many  with  living 
wills,  also  change  their  minds  regarding  their 
preferred  CPR  status  after  learning  more  about 
CPR  and  its  outcomes,  especially  regarding  func- 
tional and  cognitive  impairment.  Thus,  prefer- 
ences regarding  resuscitation  are  neither  fixed 
nor  always  based  on  adequate  information.3 
When  a living  will  does  exist,  vague  language 
often  forces  physicians  and  others  to  infer  spe- 
cific treatment  choices  such  as  the  choice  to 
forego  CPR.  The  physician  cannot  view  these 
unclear  documents  as  reliable  expressions  of 
treatment  preference.  These  documents  are  not 
a substitute  for  informed  discussion. 

While  the  idea  of  informed  discussion  seems 
an  appropriate  way  to  address  concerns  of  pa- 
tient autonomy,  the  actual  implementation  of 
informed  discussion  is  difficult  and  cumber- 
some. When  should  advance  CPR  discussions 
take  place  and  exactly  what  information  should 
be  shared  and/ or  discussed?  For  patients  who 
are  in  the  acute  stage  of  their  illness,  do-not-re- 
suscitate  decisions  are  of  most  clinical  relevance 
when  made  at  the  time  of  admission,  as  these 
patients  are  most  likely  to  experience  cardiac 
arrest  within  48  hours  of  admission.4  However, 
some  think  it  is  impractical  and  unnecessary  to 
discuss  CPR  decisions  with  most  acutely  ill,  eld- 
erly patients  at  the  time  of  admission.  Many  of 
these  patients  are  not  competent  to  discuss  de- 
cisions at  time  of  admission  and  for  those  who 
are  competent,  many  physicians  may  think  it 
best  to  spare  patients  these  often-distressing  dis- 
cussions on  the  grounds  that  CPR  would  most 
likely  be  futile.  In  Bacon's  opinion,  "It  is  realis- 
tic, not  paternalistic,  to  say  that  most  DNR  deci- 
sions for  such  [elderly,  acutely  ill]  patients 
should  be  made  by  doctors  who  usually  do  not 
need  to  discuss  them  with  patients."4  However, 
according  to  others,  most  elderly  patients  are 
indeed  willing  to  discuss  their  CPR  status  and 
most  of  those  willing  to  discuss  their  CPR  sta- 
tus are  ultimately  willing  to  follow  their  doctor 's 


644  J La  State  Med  Soc  VOL  152  December  2000 


Health  Law  and  Biomedical  Ethics 


advice  regarding  the  appropriateness  of  CPR.5 
Even  with  informed  discussion,  health  care  pro- 
viders will  not  be  able  to  communicate  or  teach 
patients  about  all  of  the  possible  situations  in 
which  resuscitation  may  become  an  option.  For 
this  reason,  limiting  CPR  availability  to  those 
situations  where  positive  outcomes  may  be  rea- 
sonably obtained  still  shows  respect  for  patient 
autonomy  and  the  permission  process.  In  other 
words,  respect  for  patient  autonomy  does  not 
create  a right  for  patients  to  demand  CPR  in  all 
situations. 

There  are  several  patients,  though,  who  are 
indeed  positive  that  they  do  not  want  to  be  re- 
suscitated if  they  experience  cardiac  arrest.  Due 
respect  must  be  given  to  a patient's  desire  to  be 
allowed  to  die.  To  attempt  CPR  on  such  a pa- 
tient who  has  refused  CPR  would  not  only  vio- 
late the  patient's  autonomy,  but  the  act  of  per- 
forming CPR  may  also  be  considered  maleficent. 
Limiting  CPR  acknowledges  the  wish  to  die 
without  intervention. 

JUSTICE 

According  to  Hilberman  et  al,  "Moral  justice 
considerations  involve  the  creation  of  rights  to 
receive  something,  the  resolution  of  competing 
individual  demands,  and  the  balancing  of  so- 
cial goals."1  Regarding  CPR,  one  of  the  questions 
they  ask  is,  "Can  we  afford  to  make  CPR  and 
other  expensive  medical  interventions  univer- 
sally available?"  Justice,  more  so  than  the  other 
three  bioethical  principles,  forces  us  to  deal  with 
the  fact  that  health  care  resources  are  indeed  lim- 
ited. Cost  issues  must  be  addressed.  It  is  not 
possible  to  deliver  all  medical  interventions  re- 
gardless of  effectiveness.  So,  Hilberman  et  al,  in 
order  to  help  identify  which  interventions  are 
more  effective,  propose  that  interventions  that 
are  considered  basic  medical  care  should  meet 
the  following  criteria: 

1.  The  intervention  should  prevent,  cure,  pal- 
liate, or  yield  a one-year  survival  greater  than 
75%; 

2.  It  should  produce  little  toxicity  or  long-term 
disability; 


3.  It  should  be  affordable;  and 

4.  It  should  be  distinctly  more  beneficial  than 
burdensome 

They  consider  other  therapies  either  optional  or 
experimental. 

They  apply  these  criteria  to  CPR  and  make 
the  following  CPR  classification  groups: 

1.  CPR  in  patient  groups  with  anticipated  sur- 
vival of  20%  to  50%  is  experimental  care, 
generally  beneficial,  in  need  of  further  evalu- 
ation and  refinement. 

2.  CPR  with  anticipated  survival  of  5%  to  20% 
is  marginal  experimental  care,  in  need  of  fur- 
ther evaluation  and  refinement. 

3.  CPR  with  expected  survival  below  5%  or 
with  delayed  initiation  has  proven  an  unsuc- 
cessful experiment  and  is  not  to  be  per- 
formed. 

To  summarize  the  ethical  argument  of 
Hilberman  et  al,  the  selective  use  of  CPR  is  de- 
termined by  the  balancing  of  burdens  and  ben- 
efits with  the  obligation  to  avoid  known  harm- 
ful actions.  It  is  the  responsibility  of  the  provider 
to  balance  the  bioethical  principles  appropri- 
ately. Decisional  authority  to  use  or  withhold 
CPR  should  reside  with  the  health  care  provid- 
ers because  their  expertise  and  knowledge  is 
superior  to  that  of  the  patient.  Within  this  frame- 
work, the  provider  is  still  able  to  respect  patient 
autonomy.  Justice  considerations  also  support 
limited  use  of  CPR  and  force  us  to  more  closely 
examine  what  we  consider  basic  or  universally 
available  medical  care. 

Finally,  Hilberman  et  al  recommend  a CPR 
policy:  Of  course,  cardiac  arrest  must  occur  for 
CPR  to  be  a relevant  intervention,  but  not  all 
cardiac  arrests  are  sufficient  indication  for  ini- 
tiation of  CPR.  While  this  discussion  explores 
the  limitation  of  CPR  use,  it  is  appropriate  that 
there  be  a bias  in  favor  of  its  initiation  because 
the  decision  not  to  perform  CPR  is  irreversible. 
Yes,  we  are  better  off  safe  than  sorry,  but  the  his- 
tory of  outcomes  and  ethical  considerations  still 
indicate  the  need  for  a more  limited  application 
of  CPR  than  many  present  DNR  policies  permit. 


J La  State  Med  Soc  VOL  152  December  2000  645 


Health  Law  and  Biomedical  Ethics 


Hilberman  et  al  define  when  CPR  should  be  in- 
dicated, not  indicated,  and  relatively  contrain- 
dicated: 

♦ CPR  is  indicated:  1.  For  witnessed  arrest;  2. 
For  a cardiac  rhythm  of  ventricular  fibrilla- 
tion or  tachycardia;  3.  During  operations  and 
procedures;  4.  As  part  of  well-justified  ex- 
perimental protocols. 

♦ CPR  is  not  indicated:  1.  If  the  patient  does 
not  want  CPR;  2.  If  the  arrest  is  unwitnessed, 
unless  some  sign  of  life  persists;  3.  If  CPR  is 
not  started  within  12  minutes  of  arrest,  or 
has  continued  more  than  30-45  minutes  (ex- 
cept in  the  case  of  hypothermia);  4.  For  pa- 
tients in  a persistent  vegetative  state,  in  a 
coma,  or  with  severe  heart  or  lung  failure, 
advanced  cancer,  or  other  end-stage  illness. 

♦ CPR  is  relatively  contraindicated:  1.  If  it  is 
known  that  the  patient  had  significant  physi- 
cal deterioration  prior  to  cardiac  arrest;  2.  For 
persons  who  have  severe  dementia,  and  pos- 
sibly those  with  moderate  dementia — CPR 
is  intended  to  prevent  premature  death  and 
is  not  appropriate  in  a person  who  has  ad- 
vanced and  debilitating  symptoms  of  aging; 
3.  For  patients  with  advanced  cancer,  who 
rarely  survive  CPR  according  to  outcome 
studies;  4.  For  victims  of  AIDS  for  whom 
cardiac  arrest  is  a late  complication.  Ad- 
vances in  AIDS  treatment  may  be  able  to 
delay  the  occurrence  of  cardiac  arrest,  but 
they  have  not  been  able  to  alter  the  subse- 
quent outcome. 

Given  these  indications,  a proposed  policy  sim- 
ply states  that  CPR  should  be  performed  when 
it  is  indicated,  CPR  should  not  be  performed 
when  it  has  been  refused  or  is  not  indicated,  and 
CPR  should  be  performed  infrequently  when  the 
intervention  is  relatively  contraindicated. 

Of  course  these  indications  may  be  modified 
as  new  information  emerges.  Johnson  has  pro- 
posed a similar  policy:  "Rather  than  maintain- 
ing CPR  as  an  intervention  that  can  be  avoided 
only  by  a negative  order,  [a  new  policy  should] 


support  a positive  order,  ie,  perform  CPR  when 
beneficial  unless  the  patient  refuses."6  Some 
studies  have  suggested  more  specific  guidelines 
for  more  specific  constellations  of  conditions.  For 
example,  for  patients  who  suffer  simultaneously 
from  stroke  and  another  disease,  members  of  the 
Canadian  and  New  York  Stroke  Consortiums 
have  created  disease-specific  criteria  that,  if  met, 
indicate  the  patient  should  not  be  resuscitated.7 

Another  policy  change  which  could  effec- 
tively limit  the  use  of  CPR  and  save  health  care 
resources  would  involve  allowing  paramedics 
to  make  decisions  about  withholding  or  termi- 
nating CPR.  In  Oslo,  Norway,  paramedics  are 
allowed  to  make  such  decisions.  They  use  prog- 
nostic and  ethical  criteria  without  a clear  bor- 
derline. Signs  that  they  consider  to  lead  to  a good 
prognosis,  such  as  ventricular  fibrillation,  con- 
tracted pupils,  or  normal  skin  color,  always  lead 
the  initiation  of  CPR.  They  continue  bystander 
CPR  even  if  the  professional  thinks  the  effort  is 
futile,  in  order  to  encourage  bystanders.  Social 
status  does  not  affect  the  paramedics'  decisions, 
and  advanced  age  is  a negative  criteria  only 
when  present  with  other  negative  factors  or  if 
the  relatives  wish  for  no  resuscitation.8  Some 
areas  in  the  United  States  do  have  a similar  EMS 
system  in  which  the  paramedics  are  given  more 
decision  making  responsibility;  however, 
hurdles  to  widespread  use  of  this  type  of  sys- 
tem include  the  cost  of  increased  training  of 
paramedics  and  the  cost  of  more  possible,  or 
more  likely,  litigation  which  would  include  para- 
medics as  well  as  physicians. 

The  Medical  Center  of  Louisiana's  "Guide- 
lines for  Limitation  of  Life  Sustaining  Therapies 
Including  Resuscitation  (DNR)  for  Adults"  is  a 
policy  which  appropriately  addresses  many  of 
the  above-mentioned  ethical  issues  but  still  pre- 
sents some  vague,  gray  areas.  In  accordance  with 
the  policy  proposed  by  Hilberman  et  al,  "The 
physician  has  the  ultimate  ethical  and  legal  re- 
sponsibility of  making  the  clinical  judgment  not 
to  resuscitate  or  to  limit  medically  futile  thera- 
pies. The  decision  should  be  made  in  consulta- 
tion with  the  patient  and/or  family  (II. B. 3)." 
These  guidelines  also  recognizes  patient  au- 


646  J La  State  Med  Soc  VOL  1 52  December  2000 


Health  Law  and  Biomedical  Ethics 


tonomy:  "When  patients  are  mentally  compe- 
tent adults,  they  have  the  legal  right  to  accept  or 
refuse  any  treatment  proposed  by  their  physi- 
cians and  their  wishes  must  be  recognized  and 
honored  by  their  physicians."  The  guidelines 
help  limit  the  overuse  of  CPR  by  contraindicat- 
ing life-sustaining  therapies  when  the  patient's 
condition  is  already  futile.  The  policy  also  en- 
courages physicians  to  discover  if  the  patient  has 
an  advanced  directive,  and  to  further  discuss  the 
patient's  wishes  with  the  patient  and  the  family. 
The  guideline  stating,  "patients  who  experience 
unexpected  cardiopulmonary  arrest  for  known 
or  unknown  causes  and  who  are  not  known  to 
have  refused  resuscitation  should  have  resusci- 
tation measures  performed  (I.C.)"  may  be  inter- 
preted as  encouraging  overuse  of  CPR.  As 
worded,  the  principle  promotes  the  default  use 
of  CPR — unless  a DNR  is  present,  resuscitate. 
This  may  conflict  with  the  above-suggested  posi- 
tive order:  use  CPR  when  beneficial,  unless  the 
patient  refuses.  The  guideline  as  written  discour- 
ages the  physician  from  using  judgment  in  ini- 
hating  CPR.  Instead,  the  physician  is  encouraged 
to  resuscitate  unless  the  patient  is  known  to  have 
refused  resuscitation  or  the  patient  is  in  a futile 
condition.  While  the  policy  in  one  place  ac- 
knowledges the  physician  as  the  ultimately  re- 
sponsible caretaker,  it  also  presents  guidelines 
to  direct  the  actions  of  the  physicians.  Maybe 
this  discussion  is  nit-picking  over  semantics,  or 
maybe  the  policy  is  intentionally  vague  to  allow 
physicians  room  to  use  their  judgment. 

While  the  success  rate  for  CPR  is  low  in  many 
situations,  its  use,  or  more  specifically  its  over- 
use, is  still  tolerated  for  several  reasons.  First,  it 
seems  very  inexpensive:  it  can  be  initiated  with- 
out any  medical  equipment — one  or  two  trained 
people,  not  necessarily  health  professionals,  may 
apply  CPR — and  thus  it's  easy  to  justify  its  use. 
It  is  easier  to  justify  initiating  an  intervention 
with  a low  success  rate  when  failure  costs  very 
little.  All  that's  lost  is  some  time  and  energy  from 
the  resuscitators.  Unfortunately,  many  do  not 
consider  the  cost  of  ambulance  services  to  trans- 
port numerous  persons  who  are  recently  de- 


ceased but  given  futile  CPR.  The  cost  of  at- 
tempted resuscitation  in  the  hospital  is,  of 
course,  also  significant.  The  portrayal  of  CPR  in 
the  media  also  contributes  to  its  overuse.  As 
depicted  in  movies  and  on  TV,  CPR  has  an  ex- 
aggerated success  rate.  Thus,  many  patients  en- 
ter the  hospital  with  unrealistic  understandings 
of  the  effectiveness  of  CPR.  As  far  as  providers 
are  concerned,  they  too  can  get  caught  up  in 
media  images  and  the  "hero  factor".  The  notion 
of  being  able  to  save  a life,  or  actually  bring 
someone  back  from  near  death  with  "just  your 
bare  hands"  may  lend  a certain  romanticism  to 
CPR. 

Overuse  of  CPR  is  attributable  not  only  to 
these  unrealistic  expectations  but  also  to  the  con- 
sequences of  existing  policies  and  failure  to 
honor  patient  refusal  of  CPR.  While  abundant 
outcome  data  demonstrate  the  low  success  rates 
of  CPR  when  used  in  inappropriate  situations, 
an  overly  litigious  society  has  forced  both  indi- 
vidual and  institutional  health  care  providers  to 
take  a defensive  stance.  Popular  misconceptions 
keep  health  care  workers  from  freely  applying 
their  professional  judgment. 

REFERENCES 

1.  Hilberman  M,  Kutner  J,  Parsons  D,  et  al.  Margin- 
ally effective  medical  care:  ethical  analysis  of  issues 
in  cardiopulmonary  resuscitation  (CPR).  J Med  Eth- 
ics 23:361-367. 

2.  Marco  CA,  Bessman  ES,  Schoenfeld  CN,  et  al.  Ethi- 
cal issues  of  cardiopulmonary  resuscitation:  current 
practice  among  emergency  physicians.  Acad  Emerg 
Med  1997;4:898-904. 

3.  Walker  RM,  Schonwetter  RS,  Kramer  DR,  et  al.  Liv- 
ing wills  and  resuscitation  preferences  in  an  eld- 
erly population.  Arch  Intern  Med  1995;155:171-175. 

4.  Bacon  M,  Stewart  K,  Bowker  L.  CPR  decision-mak- 
ing by  elderly  patients  [letter].  / Med  Ethics 
1998;24:134. 

5.  Mead  GE,  Turnbull  CJ.  Cardiopulmonary  resusci- 
tation in  the  elderly:  patients'  and  relatives'  views. 
JMed  Ethics  1995;21 :39-44. 

6.  Johnson  AL.  Towards  a modified  cardiopulmonary 
resuscitation  policy.  Can  J Cardiol  1998;14:203-208. 

7.  Alexandrov  AV,  Pullicino  PM,  Meslin  EM,  et  al. 
Agreement  on  disease-specific  criteria  for  do-not- 


J La  State  Med  Soc  VOL  1 52  December  2000  647 


Health  Law  and  Biomedical  Ethics 


resuscitate  orders  in  acute  stroke.  Members  of  the 
Canadian  and  Western  New  York  Consortiums. 
Stroke  1996;27:232-237. 

8.  Naess  AC,  Steen  E,  Steen  PA.  Ethics  in  treatment 
decisions  during  out  of  hospital  resuscitation.  Re- 
suscitation 1997;33:245-256. 


Mr  Montelibano  is  a third  year  medical  studen  tat 
Louisiana  State  University  Health  Sciences  Center- 
New  Orleans.  He  is  also  completing  work  for  a 
Master  of  Public  Health  degree. 


648  J La  State  Med  Soc  VOL  152  December  2000 


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650  J La  State  Med  Soc  VOL  1 52  December  2000 


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654  J La  State  Med  Soc  VOL  1 52  December  2000 


Author  Index 


A 

Abochamh,  Dia  (5)  259 
Acosta,  Andres  (7)  321 
Ahmed,  Mohammed  H.  (4)  171;  (4)  195 
Ali,  Juzar  (8)  398 

Amedee,  Ronald  G.  (1)10;  (3)  107;  (4)  142 
Ames,  Steven  C.  (7)  349 
Andrews,  Patricia  (4)  171;  (4)  195 
Applegate,  Bradford  W.  (7)  349 

B 

Baden,  M.M.  (8)405 
Bellanger,  Trade  M.  (2)  64 
Bivalacqua,  Trinity  J.  (7)  334 
Borne,  Jessica  (6)  281;  (9)  423 
Brantley,  Phillip  J.  (7)  349 
Braun,  Kurt  (8)  386 
Bray,  Bray  R.  (8)  405 
Brodner,  David  C.  (8)  370 
Brody,  Arnold  R.  (4)  181 
Bronfin,  Daneil  (11)  572 
Brown,  Charles  L.  (4)  165 
Brown,  Karla  R.  (10)  470;  (11)  546 

C 

Caesar,  Erica  M.  (2)  64 
Calimano,  Maria  (1)  16;  (7)  321 
Cambre,  Karl  (8)  393 
Canales,  Benjamin  K.  (12)  635 
Chalew,  Stuart  A.  (6)  286 
Champion,  Hunter  C.  (7)  334 
Chandler,  Rod  (10)  475 
Chen,  Vivien  W.  (4)  171;  (4)  195 
Clayton,  Jane  (8)  377 

Colon,  Gustavo  A.  (1)  18;  (2)  5;  (3)  114;  (6) 
283;  (8)  379;  (9)  425;  (11)553 
Correa,  Catherine  N.  (4)  171;  (4)  195 
Costelloe,  Colleen  (11)  551 
Crotty,  Karen  (3)  119 


D 

D’agostino,  Horacio  (5)  247 
Daberkow,  Dayton  II  (7)  328 
Daniels,  Robert  (8)  386 
De  Mouy,  Edward  (11)  551 
Depp,  Karen  (1)  7;  (2)  55 
Dozier,  Timothy  J.  (1)  41 
Dunnihoo,  Dale  R.  (9)  427 
Duplechain,  Michael  T.  (6)  289 

E 

Ellis,  Michael  S.  (9)  436 
Eve,  Sandra  (8)  398 

F 

Falchook, Gerald  (8)  398 
Fitzpatrick,  Philip  C.  (7)  314 
Flint,  Lewis  (11)  567 

Fontham,  Elizabeth  T.H.  (2)  63;  (4)  171;  (4)  195 

Foulks,  Edward  (8)  386 

Frick,  Paul  J.  (10)  497 

Friedman,  Mitchell  (4)  181 

Frohlich,  Edward  (6)  293 

G 

Gaffga,  Chris  (8)  398 
Gaines,  Greg  (11)  567 
Galland,  Holley  (10)  523 
Gallaspy,  James  W.  (7)  345 
Ghali,  Jalal  K.  (1) 

Ghosh,  Sushmita  (4)  181 
Gianoli,  Gerard  J.  (7)  314 
Gleckler,  Elisabeth  (2)  83 
Godin,  David  A.  (6)  276 
Gomila,  Remi  (7)  345 
Gordon,  Stewart  T.  (10)  504 
Graham,  H.  Devon  III  (8)  370 
Greene,  Jay  (4)  156 
Grier,  Laurie  (1)  31 
Griffies,  S.  (8)  405 
Gupta,  Akshay  S.  (12)  597 


J La  State  Med  Soc  VOL  152  December  2000  655 


H 

Hanley,  Henry  G.  (5)  235 

Hebert,  A.  Foster  (5)  218;  (6)  276;  (12)  590 

Herrera,  Guillermo  (7)  345 

Higgins,  Joseph  Jr  (4)  148 

Hilton,  Charles  (8)  386 

Hoyle,  Gary  W.  (4)  181 

Huddleston,  Harvey  T.  (9)  427 

Hugghins,  Stephanie  Y.  (7)  334 

J 

Jindal  Bobby  (9)  454 
Johnson,  Lester  (3)  125 
Jones,  Glenn  N.  (1)35;  (7)  349 

K 

Kalmar,  John  (1)  41 
Kang,  Nancy  (12)  630 
Kelley,  Mary  Lou  (10)  504 
Kelly,  Roger  E.  (5)  253 
Kyle,  Brook  L.  (12)  625 

L 

Lacey,  James  (3)  107;  (11)  546 
Lanclos,  Nicole  F.  (10)  504 
Lastrapes,  Richard  G.  (6)  289 
Leblanc,  Alice  (2)  89 
Leblanc,  Kim  Edward  (1)  35 
Letourneau,  Janis  (3)  112 
Lewis,  C.  Clinton  (1)  5;  (2)  52 
Lippincott,  Lincoln  L.  (10)  470 
Louisiana  Health  Care  Review  (4)  159 
Lorio,  Morgan  R (6)  289 
Lutz,  B.  (8)  405 

M 

Macaluso,  Joseph  Jr  (3)  119 
Madan,  Atul  (11)  567 
Malcom,  Gray  T.  (6)  296 
Marier,  Joanne  Cain  (12)  605 
Markward,  Nathan  J.  (12)  607 


Martin,  James  F.  (4)  151 

Martinez- Lopez,  Jorge  I.  (1)  8;  (2)  56;  (3)  104; 

(4)  139;  (5)215;  (6)273;  (7)311; 

(8)  367;  (9)  419;  (10)  467;  (11)  543; 

(12)  587 

McCaffery,  Kate  (2)  83 
McCluggage,  Samuel  (8)  393 
McDonald,  John  (3)  125 
McKinell,  Kelly  (11)567 
McKnight,  G.  Tipton  (7)  349 
McLay,  R.N.  (8)  405 
McMahon,  F.  Gilbert  (6)  293 
Mehan,  Daniel  J.  Jr  (7)  349 
Melton,  Pat  (10)  509 
Mendoza,  Tamra  (4)  181 
Monier,  Charles  (5)  239 
Montelibano,  Lawrence  (12)  642 
Morris,  Cindy  B.  (40  181 
Morris,  Gilbert  F.  (4)  181 
Murray,  L.  Nicole  (1)10 

N 

Nanda,  Anil  (1)31;  (11)563 

Nawas,  Soheir  (7)  345 

Neitzschman,  Harold  (1)16;  (3)  112;  (4)  148; 

(5) 223;  (6)281;  (7)321;  (8)  377; 

(9)  423;  (10)  475;  (11)  551;  (12)  597 
Nelson,  Anne  B.  (4)  181 

O 

O’Mara,  William  (5)  218 
Overstreet,  Kim  B.  (2)  78 

P 

Patel,  Sanjay  (3)  112;  (4)  148;  (6)  281;  (8)  377; 
(9)  423 

Perret,  Robert  (1)16 
Pizarro,  Antonio  R.  (7)  345 
Posner,  Stephanie  (11)  567 

Q 

Quintal,  Roberto  E.  (11)  559 


656  J La  State  Med  Soc  VOL  1 52  December  2000 


R 


Wilson,  Scott  (5)  223;  (10)  475 
Witt,  Joseph  C.  (10)  485 


Reddy,  Praveen  (1)  31;  (11)  563 


Reddy,  Pratap  C.  (5)  239 


Woodworth,  Bradford  A.  (7)  314 
Wu,  Xiao  Chang  (4)  171;  (4)  195 


Riddick,  Frank  Jr  (8)  386 
Rigby,  Perry  (8)  386 


Y 


Rivera,  Edwin  (5)  235;  (5)  247 


Roberts,  Madeline  (2)  83 
Rodriguez,  Kimsy  (6)  276 
Rogers,  Nicole  E.  (7)  323 
Roy,  Nenita  (5)  230 


Yount,  Royce  Dean  (11)  559 


Z 


Zieske,  Arthur  W.  (6)  296 


S 


Sartor,  Oliver  (4)  190 

Saunders,  Laurel  A.  (10)  477 

Savoie,  Bobby  (2)  74 

Sawyer,  Mike  M.  (5)  225 

Schaffer,  Stephen  B.  (4)  142;  (12)  590 

Schmidt,  Beth  A.  (4)  171;  (4)  195 

Sehon,  James  (3)  125 

Shah,  Mrugeshkumar  K.  (7)  334 

Sheridan,  Frank  M.  (5)  232;  (5)  235;  (5)  259 

Spector,  Richard  A.  (9)  429 

Strong,  Jack  P.  (6)  296 

Sumrall,  Liz  (2)  83 


Tan,  Chun  Wang  (11)  559 
Tandon,  Neeraj  (5)  239 
Thurmon,  Theodore  F.  (1)  21 
Trachtman,  Louis  (2)  64;  (2)  74 
Trepagnier,  Danielle  M.  (12)  616 


Vanderheyden,  Amanda  (10)  485 
Vannedmreddy,  Prasad  S.S.V.  (1)  31 
Ventura,  Hector  O.  (4)  151 


Wallick,  Mollie  (8)  393 
Whiting,  Ray  S.  (4)  161 
Williams,  Donna  (4)  161;  (4)  165 


T 


V 


W 


J La  State  Med  Soc  VOL  152  December  2000  657 


Subject  Index 

A 

acid  ingestion  (Dec)  590 

act,  managed  care  freedom  of  choice  (Dec)  635 

activator  (May)  253 

alkali  ingestion  (Dec)  590 

Alliance  of  the  LSMS 

The  Value  of  Membership  (Jan)  7 
LSMSA  Website  Bursts  Onto  the  Scene 
(Feb)  55 

Of  Course  Change  is  a Risk  (May)  230 
American  Heart  Association  (May)  232 
aneurysm,  aortic  (May)  259 
antitrust  (Dec)  635 
artery,  coronary  (June)  296 
atherosclerosis  (June)  296 
arrhythmias,  cardiac  (May)  239 

B 

barotrauma  (Mar)  107 
behaviors 

aggressive  (Oct)  485 
noncompliant  (Oct)  485 
biotechnology  (Dec)  607 
blood  pressure,  systolic  (June)  293 
browlift  (Aug)  370 
bruit  (Apr)  148 
burns  (Dec)  590 

C 

cancer 

breast  (Apr)  161;  (Apr)  165 

chemoprevention  (Apr)  190 

control  (Apr)  161 

funding  (Apr)  161 

grants  (Apr)  161 

hepatoma  (Apr)  190 

legislation  (Apr)  165 

lung  (Apr)  181;  (Apr)  190 

patient  education  (Apr)  165 

prostate  (Apr)  161;  (Apr)  190;  (Apr)  195 

tobacco  control  (Apr)  161 

tumor  registry  (Apr)  161 


carcinoma 

esophageal  (Dec)  590 
prostate  (Apr)  195 
renal  cell  (Mar)  119 
cardiac  standstill,  transient  (Feb)  26 
catheter  (May)  239 
cesarean  section  (Nov)  553 
children  (Oct)  523 
communication  (July)  328 
community  building  (Feb)  83 
compliance  (July)  349 
counseling  (Dec)  630 
cyst 

ganglion  (Nov)  563 
synovial  (Nov)  563 

D 

diabetes  (June)  286 
disease 

cardiovascular  (May)  232 
Meniere’s  (July)  314 
Sutton’s  (Jan)  10 
disorder,  conduct  (Oct)  497 
dissection,  aortic  (May)  259 
DNA  testing  (Jan)  21 
drugs,  prescription  (Sept)  454 

E 

ECG  of  the  Month 

Reading  T Leaves  (Jan)  8 
Sinister  Implications  (Feb)  56 
Appearances  Are  Deceiving  (Mar)  104 
Disturbing  Findings  (Apr)  139 
Not  So  Obvious  (May)  215 
Nowhere  To  Go  (June)  273 
Short  Circuit  (July)  311 
The  Untamed  Heart  (Aug)  367 
Concordance  or  Discordance  (Sept)  419 
Give  P’s  A Chance  (Oct)  467 
Pay  Close  Attention  (Nov)  543 
Not  To  Be  Sneezed  At  (Dec)  587 
education 

admissions  (Aug)  393 
community  (Aug)  398 
distance  learning  (Feb)  78 


658  J La  State  Med  Soc  VOL  152  December  2000 


graduate  medical  education  (Aug)  386 
internet,  on  the  (Feb)  78 
Medical  Education  Commission  report 
(Aug)  386 

MPH  degree  programs  (Feb)  78 
physician  education  (Dec)  630 
public  health  (Feb)  78 

encephalomyopathy,  mitochondrial  (June)  281 
endoscopy  (Dec)  590 

endproducts,  advanced  glycated  (June)  296 

esophagus  (Dec)  590 

ethics,  medical  (Dec)  616;  (Dec)  642 

F 

face,  aging  upper  (Aug)  370 
failure 

Pomeroy  (Sept)  427 
tubal  sterilization  (Sept)  427 
firearms  (Oct)  523 
fish  (Feb)  64 

G 

H 

health  care,  rural  (Feb)  89 
hearing  loss  (July)  314 
hemangioma  (Jan)  16 
history,  family  (Jan)  21 
HIV  (Nov)  567 
HMO  (Dec)  635 
hoarseness  (Apr)  142 
holoprosencephaly  (Nov)  546 
homeless  (Aug)  398 
hypertension 

new  therapies  (July)  334 
maximizing  medication  adherence 
(July)  349 

renovascular  (May)  247 
treatment  (June)  293 
treatment  options  (July)  334 


I 

illness,  mental  (Aug)  405 

imaging,  magnetic  resonance  (Jan)  31 

income,  low  (July)  349 

infarction,  acute  myocardial  (Nov)  543 

infection,  sinus  (Oct)  470 

injury,  (Oct)  523 

inner  ear  (Mar)  107 
middle  ear  (Mar)  107 
superior  laryngeal  nerve  (Apr)  142 
internet  (Sept)  436 


J 

Journal  100  and  150  Years  Ago 

January  1850  and  1900  (Jan)  18 
February  1850  and  1900  (Feb)  59 
March  1850  and  1900  (Mar)  114 
April  (Frontal  Lobe  Damage  and  the  Case 
of  Phineas  Gage)  (April)  151 
May  (A  Grits  Mill:  The  Story  of  Field 
Memorial  Hospital)  (May)  225 
June  1850  and  1900  (June)  283 
July  (Joseph  E.  Murray,  MD:  Profound 
Achievement  Through  Plastic  Surgery) 
(July)  323 

August  (A  Clinical  Report  on  Intravenous 
Saline  Infusion  in  the  Wards  of  the  New 
Orleans  Charity  Hospital  from  June 
1888  to  June  1891)  (Aug)  379 
September  (Some  Interesting  Notes) 

(Sept)  425 

October  (Walker  Percy’s  Magic  Mountain) 
(Oct)  477 

November  (Preparation  for  and  Description 
of  the  Cesarean  Section)  (Nov)  553 
December  (University  of  Louisiana) 

(Dec)  600 


J La  State  Med  Soc  VOL  152  December  2000  659 


K 


L 

Lafayette’s  family  practice  residency  (Jan)  35 

laryngofissure  (May)  218 

laryngoscopy  (May)  218 

larynx  (May)  218 

liver  (Jan)  16 

LSMS 

Annual  Report  (March  Supplement) 

M 

mass,  popliteal  (Apr)  148 
medication,  free  (July)  349 
mercury,  blood  level  (Feb)  64 
mice,  transgenic  (Apr)  181 
Murray,  Joseph  E.  (July)  323 
muscle,  cricothyroid  (Apr)  142 
myopathy  (Jan)  41 
myopathy,  imaging  of  (Jan)  41 
myositis,  orbital  (Sept)  423 

N 

nasal  pyriform  aperture  stenosis,  congenital 
(Nov)  546 

O 

obesity  (Jan)  21 
obstruction,  airway  (June)  276 
obstruction,  nasal  airway  (Nov)  546 
osteopoikilosis  (July)  322 
Otolaryngology/Head  & Neck  Surgery  Report 
Recurrent  Aphthous  Stomatitis  (Jan)  10 
The  Otologic  Manifestations  of  Barotrauma 
(Mar)  107 

Superior  Laryngeal  Nerve  Injury  After 
Thyroid  Surgery  (Apr)  142 
External  Laryngeal  Trauma  (May)  218 
Tracheal  Stenosis  (June)  276 
Meniere’s  Disease  (July)  314 


Surgical  Management  of  the  Aging  Upper 
Face  (Aug)  370 

Medical  Management  of  Pediatric  Chronic 
Sinusitis  (Oct)  470 
Congenital  Nasal  Pyriform  Aperture 
Stenosis  (Nov)  546 
Caustic  Ingestion  (Dec)  590 

P 

P53  (Apr)  181 
pain,  pelvic  (July)  345 
paralysis,  vocal  cord  (Apr)  142 
parish  health,  profiles  (Feb)  83 
personality  inventory  (Aug)  393 
plasminogen,  Tissue  (May)  253 
preexcitation,  ventricular  (July)  312 
President’s  Message 

Our  Access  to  Better  Care  Plan  (Jan)  5 
2000  Legislative  Session  (Feb)  52 
2000  Legislative  Session  (Mar)  101 
Physician  Involvement  Leads  to  Good 
Medicine  (Apr)  137 
property,  intellectual  (Dec)  607 
prosthesis,  blood  vessel  (May)  259 
pseudotumor,  adductor  muscle  (Oct)  475 
psychology  (Aug)  393 
public  health  (Aug)  398 
pulse  pressure  (June)  293 

Q 

quadriceps,  sparing  (Jan)  41 

R 

radiculopathy  (Nov)  563 
Radiology  Case  of  the  Month 

Right  Upper  Quadrant  Pain  and  Palpable 
Mass  (Jan)  16 
Abdominal  Mass  (Mar)  112 
Lower  Extremity  Bruit  (Apr)  148 
My  Aching  Hip  (May)  223 
Cerebrovascular  Accident  (June)  281 
Abnormal  Bone  Survey  in  a Cancer  Patient 
(July)  321 


660  J La  State  Med  Soc  VOL  152  December  2000 


Incidental  Discovery  on  Mammography 
Done  for  a Palpable  Breast  Mass 
(Aug)  377 

Painful  Eye  (Sept)  423 
A Groin  Mass  (Oct)  475 
Congenital  Limb  and  Bleeding  Disorder 
(Nov)  551 

Constipation  Since  Birth  (Dec)  597 
regulations,  health  (Feb)  74 
relationship,  patient  (July)  328 
resuscitation,  cardiopulmonary  (Dec)  642 
retirees  (Sept)  454 
rhinosinusitis  (Oct)  470 
rhythm,  trigeminal  (Mar)  104 
Robert  Wood  Johnson  Foundation  (Feb)  89 

S 

saline  solution,  intravenous  (Aug)  379 
sanitary  code,  Louisiana  (Feb)  74 
sanitation  requirements  (Feb)  74 
sarcoidosis  (Mar)  125 
sarcoma,  synovial  (June)  289 
selenium  (Apr)  190 

shunts,  thrombosed  dialysis  (Nov)  559 

smoking  (June)  296 

sores,  canker  (Jan)  10 

spine,  lumbar  (Nov)  563 

splenosis  (July)  345 

states,  southeastern  (Feb)  89 

stem  cell,  research  (Dec)  616 

stenosis,  renal  artery  (May)  247 

stenosis,  tracheal  (June)  276 

stents  (May)  218;  (May)  259 

sterilization  failure,  long-term  (Sept)  427 

stomatitis,  aphthous  (Jan)  10 

strictures  (Dec)  590 

stroke,  ischemic  (May)  253 

students  (Aug)  393 

surgery 

plastic  (July)  323 
thyroid  (Apr)  142 

syndromes 

acute  ischemic  cardiac  (Jan)  8 

Dandy-Walker  (Jan)  31 
obesity  (Jan)  21 

thrombocytopenia  absent  radius  (Nov)  551 


T 

tachycardia,  supraventricular  (Aug)  367 
technology  transfer  (Dec)  607 
tendon,  biceps  rupture  (June)  289 
teratoma  (Mar)  112 
therapies,  new  (July)  334 
therapy,  stroke  (May)  253 
therapy,  thrombolytic  (May)  253 
thyroid  nodule  (Mar)  125 
tomography,  computed  (Jan)  31 
tracheal  resection  (June)  276 
traits,  callous-unemotional  (Oct)  497 
trauma,  laryngeal  (May)  218 
trauma,  splenic  (July)  345 
tuberculosis 

screening  (Aug)  398 
treatment  (Aug)  398 
Walker  Percy’s  fight  with  (Oct)  477 
tumor 

granular  cell  (Aug)  377 
ovarian  (Mar)  112 

U 

ulcers,  aphthous  (Jan)  10 
unions,  physician  (Dec)  635 

V 

Violence 

community  (Oct)  504 
domestic  (Dec)  630 
prevention  (Oct)  497;  (Oct)  509 
youth  (Oct)  497;  (Oct)  523 

W 

Walker  Percy  (Oct)  477 
web  sites 

health  care  (Sept)  436 
medical  (Sept)  436 
Williams,  Tennessee  (Aug)  405 


J La  State  Med  Soc  VOL  152  December  2000  661 


Advertisers 


Autoflex  Leasing 651 

Diagnostic  Imaging Inside  Front  Cover,  Outside  Back  Cover 

Gachassin  Law  Firm 596 

LAMMICO 604 


Louisiana  Department  of  Health  & Hospitals,  Office  of  Public  Health  and 


the  American  Lung  Association 649 

Medical  Protective  Company Inside  Back  Cover 

Milling  Benson  Woodward 585 

Onebane,  Bernard,  Torian,  Diaz,  McNamara  & Abell 586 

Tulane  School  of  Public  Health 641 


662  J La  State  Med  Soc  VOL  152  December  2000 


8632 


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